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A TREATISE 



INTRACRANIAL DISEASES: 



INFLAMMATORY, ORGANIC, AND SYMPTOMATIC. 



BY 



CHARLES PORTER HART, M.D., 



LATE SPECIAL LECTURER ON DISEASES OF THE NERVOUS SYSTEM IN PULTE MEDICAL COLLEGE 
MEMBER OP THE AMERICAN ASSOCIATION FOR THE ADVANCEMENT OF SCIENCE; HON- 
ORARY MEMBER OF THE COLLEGE OF PHYSICIANS AND SURGEONS OF 
MICHIGAN; AUTHOR OF "DISEASES OF THE SPINAL 
MARROW AND ITS COVERINGS," " DIS- 
^^" /\ 3 EASES OF THE NERVOUS SYS- 

TEM," ETC., ETC. 






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PHILADELPHIA: 

F. E. BOEBICKE, 

HAHNEMANN PUBLISHING HOUSE. 

1884. 



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Copyright, F. E. Boericke, 1884. 




PREFACE 



The present work on Intracranial Diseases embraces inflam- 
matory, organic, and symptomatic affections of the brain and 
its membranes — diseases which are quite as important, and as 
frequently met with in practice, as those contained in my 
work on Diseases of the Nervous System. Though intended 
chiefly as a Supplement to the latter work, I have endeavored 
to render it so complete in itself, as to present within a 
moderate compass the leading views of those most advanced 
in cerebral pathology and therapeutics, and, at the same time, 
furnish a safe and sufficient guide to those who may be dis- 
posed to consult its pages for information on these interesting 
and important subjects. 

As the diagnosis of intracranial diseases is frequently at- 
tended with considerable difficulty, I have prefixed a few 
chapters on matters pertaining to the regional diagnosis of 
cerebral affections ; for, as M. Charcot has well said in the 
preface to the American edition of his Lectures, " The exposi- 
tion of the principles underlying the doctrine of cerebral 
localization seems to have now become a necessar}^ chapter of 
introduction to the practical study of diseases of the brain." 

In conclusion, I desire to acknowledge with grateful feelings 
the generous appreciation bestowed by the profession upon 
my former writings, especially those pertaining to the nervous 
system, and to express the hope that the present addition 
thereto will be found to possess merits entitling it to a like 
favorable reception. 

C. P. H. 

Wyoming, 0., Jan., 1884. 



CONTENTS. 



PART I. 
Matters Pertaining to Regional Diagnosis. 

SECTION I. 

Physiological Considerations. 

CHAPTER I. 

Functions of the Cerebrum. 

Discovery of the cortical centres — Ferrier's experiments on the brain of an ape — 
Summary of the results obtained by Fritsch, Hitzig, and Ferrier — How the 
discrepancies between them may be accounted for — Methods employed in the 
investigation — Situation of the motor centres in man — Goltz's method of re- 
search — Broca's discovery confirmed — How these discoveries are regarded by 
Eckhard, Schiff, and others — Lussana and Lemoigne's objections — Brown- 
S6quard's views — 'Arguments in support of the cortical theory of localization 
— Objections answered — Confirmed by clinical experience — Law of functional 
substitution — The sensory centres — Facts which appear to be satisfactorily 
established — Volition and intelligent consciousness — The seat of intelligent 
language in man, 17 

CHAPTER II. 

Functions of the Cerebral Ganglia. 

Meynert's ganglia of the tegmentum pedunculi and pes pedunculi — Effects pro- 
duced by electric stimulation of the corpora striata — Hemianesthesia — Luy's 
four divisions of the optic thalamus — Functions of the corpora quadrigemina 
— Experiments of Hensen and Voelkers — Unilateral destruction of the corpora 
quadrigemina — Adamiik on stimulution of the nates — Expression of the emo- 
tions — Muscular coordination — Epileptic moans and cries — Functions of the 
crura cerebri and pons Varolii — Automatic movements — Functions of the 
cerebellum — Vertigo — Priapism — Diabetes, 30 



10 CONTENTS. 

CHAPTER III. 

Functions of the Bulb. 

Receives and transmits both sensory impressions and motor impulses — Crossed 
paralysis — Reflex coordination — The respiratory centre — The cardio-inhibi- 
tory centre — The vaso-motor centre — The emotional centre — The centre for 
deglutition — The cesophagal and gastric centre — The salivary centre — The 
centre for articulate speech — The diabetic centre — General centre for the 
coordination of muscular movements, ...... 38 

SECTION II. 

Regional Diagnosis in Brain Diseases. 

CHAPTER I. 

Cerebral Lesions. 

What lesions are of special value in establishing the theory of cortical localization — 
No known systemic lesions in the brain — Predominant influence of vascular 
lesions — No known anatomical centres of mental affections — Differentiation 
by elevation of temperature and by motor phenomena— Latent disease of the 
cortex — Convulsions — Sensory disturbances — Aphasic symptoms — Word- 
deafness — Paralysis — Monoplegias — Associated symptoms — Transient pa- 
ralysis — Destructive lesions — Secondary degeneration, ... 41 

CHAPTEK II. 

Lesions of the Basal Ganglia. 

Cerebral hemiplegia accompanied with cerebral hemianesthesia — Central cere- 
bral hemiplegia — Temporary and persistent hemiplegia — Cerebral hemi- 
anesthesia — Destructive lesions of the internal capsule — Vaso-motor disturb- 
ances — Hemichorea — Thalamic lesions — Homonyomous hemiopia — Athetosis 
and unilateral tremor — Disorders of psycho-motor reflex actions — Lesions of 
the nates — Lesions of the testes, . 47 

CHAPTER III. 

Lesions of the Cerebellum. 

General character of cerebellar symptoms — Cerebellar paralysis — Vomiting — 
Amaurosis — Incoordination of movement — Lesions of the middle lobe — 
Excitation of the genital functions — Lesions of the middle peduncle — Vertigo 
— Anarthia, headache, etc. — Diagnostic lesions, .... 53 

CHAPTER IV. 

Lesions of the Cerebro-spinal Isthmus. 

Systemic lesions — Alternate paralysis — Lesions of the pons Varolii — Apoplectic 
symptoms and rise of temperature — General paralysis — Epileptiform convul- 



CONTENTS. 11 

sions — Diabetes mellitus and insipidus — Albuminuria — Muscular rigidity — 
Emotional weakness — Lesions of the medulla oblongata— Implication of 
special nerves — Disturbances of respiration, circulation, etc. — Value of nega- 
tive symptoms, 57 



PART II. 
Intracranial Diseases. 

SECTION I. 

Cerebral Affections. 

CHAPTER I. 

Anemia of the Brain. 

The intracranial circulation — The cerebro-spinal fluid — The three principal forms 
of cerebral anaemia, namely, the irritative, apoplectic, and syncopal— Symp- 
toms — Symptoms in the aged — Syncope — Vaso-motor anaemia — Paresis and 
paralysis — Causes — Diagnosis — Prognosis — Morbid anatomy — Pathology — 
Treatment — General and special indications, 62 

CHAPTER II. 

Cerebral, Hyperemia. 

Active and passive hyperaemia — Symptoms of excitation— Symptoms of depres- 
sion — Headache — Hyperesthesia of the special senses — General anaesthesia — 
Irritability of the vascular system — Krishaber's investigations — The delir- 
ious, convulsive, and apoplectic forms — Causes — Diagnosis — Prognosis — 
Morbid anatomy — Pathology — Treatment— General indications— Special in- 
dications, 73 

CHAPTER III. 

Cerebral Apoplexy. 

Definition— Symptoms — Hemiplegia — Causes — Cerebral haemorrhage — Haemor- 
rhage into the cerebral membranes — Embolism of cerebral arteries — Cere- 
bral hyperaemia — Sunstroke — Uraemic and alcoholic intoxication, . 91 

CHAPTER IV. 

Cerebral Hemorrhage. 

Definition — Comparative frequency in different parts of the brain — Symptoms — 
Apoplectic and paralytic forms — Variations in the animal temperature — 
Conjugated deviations of the eyes and head — Symptoms of the second stage 



12 CONTENTS. 

Acute bed-sores — Hemiplegia— "-Facial paralysis — Paralysis of the extremities 
— Secondary contraction — Causes — Diagnosis — Prognosis — Morbid anatomy 
— Pathology — Treatment — General and special indications, . . 93 

CHAPTER V. 

Cerebral Thrombosis. 

Definition — Symptoms — Marantic thrombosis — Venous thrombosis in the adult 
— Causes — Diagnosis — Prognosis — Morbid anatomy and pathology — Athero- 
matous degeneration of the cerebral arteries — Illustrative case — Heubner's case 
— Eed and yellow softening — Treatment, . . . . . . Ill 

CHAPTER VI. 

Cerebral Embolism. 

Definition — Symptoms — Causes — Multiple emboli — Brown hospital case — Diag- 
nosis — Prognosis— Cerebral softening — Morbid anatomy and pathology — 
Virchow, Cohnheim and Schiitzenberger's observations — Partial cerebral 
anaemia and softening — Treatment, . • 116 

CHAPTER VII. 

Cerebral Softening. 

Definition — Symptoms — Anaemia and red softening — Yellow and white softening 
— Variations of temperature — Mental debility — Paralysis — Headache 1 — Apha- 
sia — Chronic softening — Causes — Diagnosis— Prognosis — Morbid anatomy 
and pathology — Treatment — General and special indications, . 121 

CHAPTER VIII. 

Encephalitis. 

Definition — Symptoms — Symptoms in the aged — When complicated with menin- 
gitis — Cerebral abscess — Causes — Diagnosis — Prognosis — Morbid anatomy 
and pathology — Treatment, 130 

CHAPTER IX. 

Cerebral Hypertrophy. 

Definition — Symptoms — Causes — Diagnosis — Prognosis — Morbid anatomy and 
pathology — Treatment, 137 

CHAPTER X. 

Cerebral Atrophy. 

Definition — Symptoms — Partial atrophy — General atrophy — Causes — Diagnosis 
— Prognosis — Morbid anatomy and pathology — Treatment — Electricity, 139 



CONTENTS. 13 

CHAPTER XL 
Primary Multiple Sclerosis. 
Definition — Charcot's researches — Symptoms — Sclerosis limited to the hemi- 
spheres — Muscular incoordination — Causes — Diagnosis — Paralysis agitans and 
chorea — Prognosis — Morbid anatomy — Pathology — Secondary multiple scle- 
rosis — Treatment, 143 

CHAPTER XII. 

Athetosis. 
Definition — Symptoms —Causes — Diagnosis — Post-hemiplegic chorea — Prognosis 
— Morbid anatomy and pathology — Dr. Ringer's case — Treatment, 148 

CHAPTER XIII. 
Progressive Facial Atrophy. 
Progressive laminar aplasia — Symptoms — Facial atrophy — Causes — Diagnosis — 
Morbid anatomy and pathology — Vulpian's views — Treatment, . 151 

CHAPTER XIV. 
Myxcedema. 
Definition — Symptoms — Diagnosis — Tricuspid regurgitation — Scleroderma — 
Prognosis — Morbid anatomy and pathology — Treatment, . . 154 

CHAPTER XV. 

Cerebral Tumors. 

Varieties— Glioma — Psammoma— Cholesteatoma — Xeuroma— Cancer of the brain 

— Tuberculous and syphilitic tumors — Mucous, lipomatous, cystic, and mel- 

anoid tumors — Symptoms — Causes — Diagnosis — Prognosis — Morbid anatomy 

and pathology — Aneurismal tumors — Treatment— General indications, 157 

CHAPTER XVI. 
Cerebral Syphilis. 
Xature — Varieties — Symptoms — Congestive, vascular, and syphilomatous forms 
— Causes — Diagnosis — Syphilitic thrombosis — Prognosis — Morbid anatomy 
and pathology — Treatment, 164 

SECTION II. 

Meningeal Affections. 

CHAPTER I. 
Simple Acute Meningitis. 
Lepto-meningitis cerebralis — Symptoms — Morbid anatomy — Pathology — 
Causes — Diagnosis — Prognosis — Treatment — General indications — Special 
indications, 171 



14 CONTENTS. 

CHAPTER II. 

Tubercular Meningitis. 
Definition — Leptomeningitis — Symptoms — Prodromic stage — Symptoms of ex- 
citement — Symptoms of depression — Closing stage — Morbid anatomy — Pa- 
thology — Etiology — Diagnosis — Tache cerebrale — Prognosis — Treatment — 
General and special indications, 179 

CHAPTER III. 

Traumatic Meningitis. 
Forms — 1. Pachymeningitis — Symptoms — Treatment — 2. Arachnitis — Morbid 
anatomy — Symptoms — Etiology — Diagnosis — Prognosis — Treatment — 3. Lep- 
tomeningitis — Symptoms — Morbid anatomy - — Pathology — Complication — 
Prognosis — Treatment, . • . . 189 

CHAPTER IV. 

Chronic Meningitis. 

1. Chronic convexital meningitis — Symptoms — Morbid anatomy and pathology — 

Causes — Diagnosis — Prognosis — Treatment — 2. Chronic basilar meningitis — 

Symptoms — Morbid anatomy — Pathology — Causes — Diagnosis— Prognosis — 

Treatment— General and special indications, 195 

CHAPTER V. 
Epidemic Meningitis. 
Cerebro-spinal meningitis — Symptoms — Complications and sequalse — Morbid 
anatomy — Pathology — Causes — Diagnosis — Prognosis — Treatment — Special 
indications, . 203 

CHAPTER VI. 

HEMORRHAGIC PACHYMENINGITIS. 

Hsematoma durse matris — Symptoms — Morbid anatomy and pathology — Views of 
Virchow and Huguenin — Causes — Diagnosis — Prognosis— Treatment, 214 

CHAPTER VII. 

Chronic Hydrocephalus. 
Dropsy of the brain— Symptoms — Morbid anatomy and pathology — Enlargement 
of the head — Facies hydrocephalica — Causes — Diagnosis — Prognosis — Treat- 
ment — Special indications, 218 

CHAPTER VIII. 

Foreign Products. 
Serum — External hydrocephalus — Serous apoplexy — Thrombi — Thrombosis of 
the longitudinal sinus — Thrombosis of the lateral sinuses — Parasites — Cys- 
ticerci — Hydatids— Prognosis — Treatment, . . . . • . 225 



CONTENTS. 15 

SECTION III. 

Symptomatic Affections. 

CHAPTER I. 

Cephalalgia. 
Headache — Varieties — 1. Congestive headache — Symptoms — Causes — Special in- 
dications — 2. Nervous headache — Symptoms — Causes— Special indications — 
3. Sympathetic headache — Varieties — General and special indications, 230 

CHAPTER II. 

Vertigo. 
Definition — Muscular coordination — Etiology and pathology — Varieties — 1. Laby- 
rinthine or auditory vertigo — Symptoms — Diagnosis — Prognosis — 2. Ocular 
vertigo — Symptoms — 3. Gastric vertigo — Symptoms — Diagnosis — 4. Nervous 
vertigo — Symptoms —5. Intracranial vertigo — Diagnosis — Treatment — General 
and special indications, 269 

CHAPTER III. 

Insomnia. 
Sleep — Sopor — Partial insomnia — Complete insomnia — Causes — Treatment — 
General indications — Special indications, ..... 282 

CHAPTER IV. 
Coma. 
Definition — Degrees of insensibility — Carus — Diagnosis — Causes — Prognosis — 
Treatment — Special indications, 286 

s, CHAPTER V. 

Sunstroke. 
Varieties — 1. Syncop a/— Symptoms — 2. Asphyxial — Symptoms — 3. Hyperpyrexial — 
Symptoms — Vaso-motor paralysis and rise in temperature — Morbid anatomy 
— Causes — Prognosis — Treatment — General and special indications, 290 

CHAPTER VI. 
Concussion of the Brain. 
Definition — Symptoms — Morbid anatomy — Pathology — Prognosis — Treatment — 
General and special indications, 297 

CHAPTER VII. 
Hydrocephaloid. 
Definition — Symptoms — Symptoms common to other diseases — Diagnosis — Treat- 
ment — Special indications, 302 



A TREATISE 



INTRACRANIAL DISEASES 



PART I. 

MATTERS PERTAINING TO REGIONAL DIAGNOSIS. 

SECTION I. 

PHYSIOLOGICAL CONSIDERATIONS. 



CHAPTER I. 

FUNCTIONS OF THE CEREBRUM. 

Although numerous experimental researches had been pre- 
viously made with a view to determine the special functions 
of different parts of the brain, it was not until the year 1870 
that the cortical portion was found to be endowed with either 
sensibility or motor excitability; previous observations tend- 
ing to show that neither pain nor convulsive action could be 
produced by stimulation or lesion of any portion of either the 
grey or white matter of the hemispheres. In that year, how- 
ever, two German physiologists, Fritsch and Hitzig, by sub- 
jecting certain parts of the cerebral cortex of a dog to a weak 
galvanic current, discovered certain centres of motion in the 
grey matter of the hemispheres, which, when thus stimulated, 
could be made to produce certain well-defined muscular move- 
ments. These physiologists, by applying electricity to differ- 
ent portions of the cerebral surface, showed (1) that the grey 
matter of the hemispheres can be directly stimulated ; (2) that 



18 INTRACRANIAL DISEASES. 

there are true motor centres in the cerebral cortex; (3) that 
the action on the muscular system is a cross-action, that is, 
that it acts only on the side opposite the seat of irritation; (4) 
that there are special centres or areas governing the move- 
ments of the extremities, the jaws, and the tongue; (5) that the 
special function of each area is limited to its particular centre, 
except so far as it may be affected by vicarious action ; and (6) 
that severe hemorrhage destroys the excitability of the grey 
matter of the cortex; thus accounting, perhaps, for the nega- 
tive results reached by previous investigators. According to 
the same authorities, the motor centres, even when contiguous 
to each other, or occupying the same convolution, may be 
connected with w y ide]y different sets of muscles. Thus, the 
centre governing the supinator and flexor muscles of the fore- 
arm is found to be in close relation with the centre controlling 
the zygomatic muscles of the face, w T hilst adjoining the latter 
is a centre affecting the movements of the eyes and head. 
These results were afterwards confirmed by Ferrier, who re- 
peated the experiments on the brain of a monkey, an ani- 
mal whose cerebral convolutions most nearly resemble those 
of man. 

The following is a brief summary of the results obtained by 
these observers, so far as they bear upon the theory of cerebral 
localization: 

1. Notwithstanding the fact that, as shown by previous in- 
vestigators, the hemispheres fail to respond to any form of 
mechanical, chemical or thermal lesion or stimulation, this is 
found not to be the case with electrical stimulation, the direct ap- 
plication of which to the surface of the hemispheres, in certain 
regions, causing definite movements in certain remote parts of 
the body; and, what is still more important, these movements 
are found to be associated with irritation of certain circum- 
scribed areas. 

2. While considerable differences exist between Hitzig and 
Ferrier in regard to the extent of cerebral localization, as well 
as in respect to the character and significance of the phe- 
nomena elicited by their experiments, the discrepancies be- 
tween them may be satisfactorily accounted for, partly by the 



FUNCTIONS OF THE CEREBRUM. 19 

manner in which they interpret them, and partly by the 
difference in their methods of investigation. 

3. The method employed by Hitzig consisted chiefly in 
applying directly to the surface of the hemispheres, by means 
of blunted electrodes, a galvanic current of sufficient intensity 
to cause a distinct sensation when applied to the tip of the 
tongue. Ferrier's method was by means of a similar applica- 
tion of the electrodes of an induced or secondary current, of a 
strength sufficient to cause a pungent, but quite bearable sen- 
sation when applied to the tongue, affording a greater degree 
of stimulation without danger of producing disorganization. 

4. An electrical current that will cause intense and indefi- 
nite action in an animal non-narcotized, w T ill, according to 
Ferrier, excite only moderate and definite action in an animal 
merely rendered insensible to pain, and no effect whatever on 
one fully anaesthetized. The state of the cerebral circulation 
also greatly modifies its excitability, haemorrhage lowering it 
in a marked degree. Great differences also exist in different 
animals, with respect to the degree and duration of the exci- 
tability of the hemispheres. Again, various regions of the 
brain differ in respect to their excitability. Thus, a current 
sufficient to cause a decided contraction of the orbicularis 
oculi, will, according to this authority, fail to produce any 
movement of the limbs. By observing this principle, using the 
faradic current, and applying a current of sufficient strength 
to produce a uniformly definite effect, Ferrier obtained positive 
results in regions of the brain in which Fritsch and Hitzig, 
with the weaker galvanic current, failed to elicit symptoms, 
and which they therefore termed inexcitable. 

5. The situation of the motor centres in man, according to 
the physiological experiments of Ferrier on the monkey, an 
animal whose brain, as already stated, most nearly resembles 
that of man, is as follows: (See Cut, page 20.) 

a. The centres for the movements of the eyes are situated on 
the posterior half of the superior and middle frontal convolu- 
tions (12), and the anterior and posterior branches of the 
angular gyrus (13, 13'). Electrical stimulation of the former 
(12) causes elevation of ilie eyelids, dilatation of the pupils, conju- 
gate deviation of the eyes, and turning of the head toward the op- 



20 



INTRACRANIAL DISEASES. 



posite side. Stimulation of the posterior centres (13, 13') causes 
the eyes to move toward the opposite side, with an upward or 
downward deviation, according as the electrodes are on one or 
the other branches of the angular gyrus. 

The connection of this region (the angular gyrus) with the 
organ of vision, has been noticed by Hitzig, Goltz, McKendrick 
and others, the first two of whom experimented upon dogs, 
and the latter upon pigeons. Ferrier objects to Goltz's method 
of research — which consisted in washing away a portion of 
the brain after trephining over the spot selected for investiga- 
tion — as not fulfilling the conditions required in investigations 




Diagram representing side view of the human brain. — (After Ferrier.) 

of this nature. Ferrier's method of localized destruction of 
special areas, was chiefly by means of the actual cautery, 
varied occasionally with excision of the part. The result of 
his experiments upon this part was, that while electrical irrita- 
tion of the angular gyrus, in which one of these motor centres 
for the eyes is situated (13, 13'), produces the movements of the 
eyes, pupils, and head above stated, its destruction causes no 
paralysis in the muscles of either the eye, its lids, or the pupils. 
Unilateral destruction of this centre, however, produces tem- 
porary blindness in the opposite eye; whilst bilateral destruction 



FUNCTIONS OF THE CEREBRUM. 21 

of this centre causes 'permanent blindness in both eyes. It is 
plain from this that the centre of each hemisphere has a pecu- 
liar effect upon both eyes, which is explained by the peculiar 
decussation of the optic nerves in the optic chiasm. It is also 
plain that, as stated by Ferrier, the movements consequent on 
electrical stimulation of this centre are merely reflex indica- 
tions of sensory stimulation. Whether, as he says, these move- 
ments are ue to the associated action of lower centres, cannot 
be experimentally determined. We shall recur to this subject 
again, under the head of sensory centres (q. v.). 

b. The centres for the movements of the jaws and tongue, are 
situated at the inferior extremity of the ascending frontal 
(Broca's) convolution, on a level with the posterior termination 
of the third frontal convolution (9 and 10). Electrical stimu- 
lation of this region is attended with opening of the mouth, and 
with protrusion (9) and retraction (10) of the tongue; action bilateral. 
These movements frequently continue after the electrodes are 
withdrawn. Ferrier found, in experimenting upon the dog, 
that the stimulation of this region also occasionally caused 
vocalization, or feeble attempts at barking or growling. In 
one experiment this was exhibited in a very striking manner. 
Each time the electrodes were applied to this region, the 
animal uttered a loud and distinct bark. To exclude the 
possibility of mere coincidence, Ferrier says he then stimu- 
lated in succession various parts of the exposed hemisphere, 
producing the characteristic reaction of each centre, but no 
barking. We shall see hereafter that Broca's convolution is, 
in man, the seat of intelligent language, and this experiment 
seems to confirm the truth of Broca's discovery, so far as ex- 
periments on the lower animals could be expected to do it. 

c. The centres for the mouth and lips are situated on the 
ascending frontal convolution, above the centres for the jaws 
and tongue (7 and 8). Electrical irritation of the upper por- 
tion of this region (7), by its connection with the zygomatic 
muscles, retracts and elevates the angle of the mouth; whilst stimu- 
lation of the lower portion (8) elevates the ala of the nose and 
upper lip and depresses the lower lip, so as to expose the canine 
teeth on the opposite side. 

.d The movements of the upper extremity are so numerous 



99 



INTRACRANIAL DISEASES. 



and complicated, as to require many individual centres. That 
for supination and flexion of the forearm, is situated on the upper 
part of the ascending frontal convolution (6); that for extension 
and forward movement of the arm and hand, is situated at the 
posterior extremity of the superior frontal convolution (5); 
and the centre for backward movement of the arm with abduction, 
the palm of the hand being directed backward, as in swing- 
ing, occupies adjacent margins of the ascending frontal and 
ascending parietal convolutions (4). Centres for the extensors 
and flexors of the individual digits could not be differentiated, 
but the prehensile movements of the opposite hand are central- 
ized in the ascending parietal convolution (a, b, c, d), the stim- 
ulation of which causes individual and combined movements of 
the fingers and wrists, ending in clenching of the fist. Paralysis 
caused by destruction of these centres, when the injury is 
limited to the cortical grey matter of the region included in 
them, is confined strictly to the voluntary movements pro- 
duced by electrical stimulation of these particular centres, and 
without affecting the sensibility of the parts over whose move- 
ments they preside. 

e. The centres for the movements of the lower extremity are 
situated on the posterior parietal lobule (1), and on the upper 
part of the ascending parietal and adjoining part of the as- 
cending frontal convolution (2). The first of these centres (1) 
when electrically excited, advances the lower or opposite hind 
limb, as in walking. Occasionally this movement is confined 
to the foot and ankle, the foot being flexed on the ankle and the toes 
widely separated. Stimulation of the other centre (2) produces 
complex movements of the thigh, leg, and foot, with adapted move- 
ments of the trunk, by which the foot is brought to the median 
line of the body, as in scratching the chest or abdomen. De- 
struction of these centres, as in the case of those governing the 
movements of the upper extremity, causes paralysis of volun- 
tary motion, without affecting the sensibility, the paralysis 
being confined to the movements resulting from electrical 
stimulation of these centres. 

6. Whilst the great majority of physiologists, including 
Fritsch, Hitzig, Ferrier and other distinguished investigators, 
regard the above-described centres as directly motor, other 



FUNCTIONS OF THE CEREBRUM. 23 

noted observers, as Eckhard, Schiff, Hermann, and Brown- 
S'-quard, attribute the movements excited by electrical stimu- 
lation of the cerebral surface to a reflex, indirect, or vicarious 
action; and that, too, notwithstanding the fact that the results 
obtained by Hitzig and Ferrier are found to agree in most 
instances with clinical and pathological observation, as we 
shall see when we come to treat of the localization of cerebral 
diseases. Some contend that the movements observed are not 
due to the excitation of the cerebral cortex, but to the trans- 
mission of irritation to the motor ganglia below; in proof of 
which they point to the fact that Eckhard has succeeded in 
tracing one of the excitable fibres for the front leg from the 
cineritious substance down to the corpus striatum. MM. Lus- 
sana and Lemoigne, who also deny that the so-called cortical 
centres are true motor centres, found their objection upon the 
fact that. mechanical stimulation does not excite them, and that 
galvanism and faradism are also generally insufficient when 
the animal is fully anaesthetised, as well as immediately after 
death. They also point to the discovery of Goltz, who, in his 
experiments upon the dog, found that the motor paralysis 
observed after destruction of the cortical centres, is neither 
complete nor permanent, like that which follows the destruc- 
tion of the lower motor centres. Hence we find Dr. Brown- 
Sequard, the most noted skeptic on this subject, using the 
following language: "Take, for instance, the sense of volition; 
we find it destroyed or altered in diseases of the brain, yet 
cases are not wanting in which certain parts of the brain have 
been destroyed while volition was not lost; and this is true of 
all the functions referred to the brain. At times alteration or 
destruction of these functions attend lesions of the brain, at 
times again these lesions are present while the symptoms are 
absent, and at times an entirely different class of symptoms 
ma)' appear. Each alleged function of the brain may remain after 
the destruction of what is considered its centre"* Brown-Sequard 
also denies the doctrine of cross-paralysis, basing his opinion 
on the histories of less than three hundred cases in which 
paralysis occurred on the same side as the cerebral lesion. 
But as he had to ransack the entire literature of medicine to 

* Lecture delivered at the Cincinnati Hospital, March 13th, 1872. 



24 INTRACRANIAL DISEASES. 

find these exceptions to the general rule, that the paralysis is on 
the side opposite to the injury, and as many of these cases were 
very old, and therefore probably incorrectly reported, his 
opinion on this point, as on that of the cortical motor centres 
generally, is diametrically opposed to that of most of his col- 
leagues. Moreover, from what Ave now know regarding the 
variations in the course of the pyramidal fibres, such excep- 
tional cases are perfectly consistent with the received rule on 
this subject. 

7. The advocates of the cortical theory of localization rely for 
the support of their doctrine chiefly on the fact, that paralysis 
of voluntary motion generally follows destruction of the correspond- 
ing cortical centres, and that any apparent exception to this 
result is capable of explanation in a way consistent with their 
view. They allege, also, that the theory derives marked sup- 
port, not only from clinical observations, but from anatomical 
and pathological considerations. They refer with emphasis 
to the researches of Betz, who found in the region anterior to 
the fissure of Rolando, corresponding to Hitzig's motor centres, 
giant-pyramidal cells, while in the region posterior to that fis- 
sure, which is not excitable, layers of nuclei predominate. Xow 
these "giant-pyramids," which occur only in Hitzig's excitable 
zone, are not fully developed until after birth. Here, then, it 
is claimed, we have a striking analogy, so far as the nervous 
elements are concerned, to the motor elements in the grey 
matter of the spinal cord. 

As for the transient character of the paralysis observed after 
destruction of cortical motor centres, it should be remembered 
that it applies only to quadrupeds ; in man and the monkey 
the paralysis is permanent. In view of this fact, Ferrier perti- 
nently asks : " If we were to say, with Hermann, that the re- 
covery in dogs disproves the view of the motor functions of 
the cortex, how shall we account for the paralysis observed in 
man and monkeys?" The explanation usually given of the 
phenomena, as met with in quadrupeds, is, that a process of 
compensation is effected by another portion of the cortex tak- 
ing on the function of that which has been lost. In the case 
of bilateral movements, it is only necessary to assume a vica- 
rious action of the corresponding centre of the opposite hemi- 



FUNCTIONS OF THE CEREBRUM. 25 

sphere. That such compensatory or vicarious action does take 
place where muscles of the opposite sides are usually associated 
in action, as in the movements of the eyes, chest, abdomen, 
etc., is evident, and seems to be satisfactorily explained by the 
theory of Dr. Broadbent, whose explanation is as follows : 
"Where the muscles of the corresponding parts on the oppo- 
site sides of the body constantly act in concert, and act inde- 
pendently, either not at all or with difficulty, the nerve-nuclei 
of these muscles are so connected by commissural fibres, as to 
be pro tanto a single nucleus. This combined nucleus will have 
a set of fibres from each corpus striatum, and will usually be 
called into action by both, but it will be capable of being ex- 
cited by either singly, more or less completely according as 
the commissural connection between the two halves is more 
or less perfect. According to this hypothesis, then, if the 
centre of volitional action of one side is destroyed, or one 
channel of motor power cut across, the other will transmit an 
impulse to the common centre, and this will be communicated 
to the nerves of the two sides equally, if the fusion of the two 
nuclei is complete, and there will be no paralysis — more or 
less imperfectly to the nerve of the affected side if the trans- 
verse communication between it and its fellow is not so per- 
fect, in which case there will be a corresponding degree of 
paralysis." 

The above theory, which is in complete harmony with the 
facts of clinical experience, not only accounts for the compara- 
tive escape of bilaterally associated movements in case of 
corpus striatum haemorrhage, which the theory was formed to 
explain, but serves also to clear up the transient nature of the 
paralysis resulting from destruction of the cortical centres in 
quadrupeds, the movements of which are more generally auto- 
matic than are those of man and the monkey. This explana- 
tion, however, is not quite satisfactory, since, after recovering 
from paralysis caused by the extirpation of one cortical motor 
centre, the destruction of the corresponding centre of the oppo- 
site hemisphere does not reinduce the paralysis from which 
the animal had previously recovered. Besides, even after the 
destruction of both cortical centres, the power of voluntary 
movement of the parts to which their influence seems to be 



2G INTRACRANIAL DISEASES. 

distributed is not entirely abolished. To account for these 
phenomena, Carville and Duret adopt the hypothesis of Flou- 
rens, Longet, and others, namely, that other portions of the 
hemispheres gradually assume the functions of the parts which 
have been destroyed. This law of functional substitution, 
however, is in direct conflict, not only with the doctrine of 
cortical localization of function, but with the results of the 
experiments on which that doctrine is founded. The law of 
substitution, in order to be consistent with the theory of 
cortical localization, requires to be limited to those centres 
of action already established — the lower ganglia — which, with- 
out resuming new functions, may in an indirect manner com- 
pensate for the loss of the upper centres. 

THE SENSORY CENTRES. 

7. We are indebted to Ferrier for most of our knowledge of 
the sensory centres of the cerebrum. We have already given 
the result of his experimental researches into that portion of 
the temporo-sphenoidal lobe known as the angular gyrus, in 
which is situated one of the motor centres controlling the 
movements of the eyes, pupils, and head, but w T hose destruction, 
while it produces no motor paralysis in the muscles of either 
the eye, the eyelids or the pupil (showing it to be not a direct 
but only a reflex motor centre), causes loss of vision in the 
opposite eye (which, however, is not permanent if the opposite 
gyrus remains sound), and when both angular gyri are de- 
stroyed, causes blindness of both eyes, which is complete and per- 
manent, thus proving it to be a true sensory centre. 

b. Pursuing his investigations, Ferrier found in the superior 
temporo-sphenoidal convolution a centre (14) which, under fara- 
dic irritation, caused the monkey operated upon to suddenly 
retract or prick up the opposite car, widely open the eyes, dilate the 
pupils, and turn the head and eyes to the opposite side — phenomena 
which a loud sound made in the ear opposite the irritated 
hemisphere would be likely to produce. This inference, as to 
the nature of the effect produced by electrical stimulation of 
this centre, was confirmed by destruction of the convolution, 
which, as in the case of the visual centre, caused apparent 
deafness on the opposite side, and, when both sides were de- 



SENSORY CENTRES. 27 

strayed, the animal became totally deaf, no motor paralysis being 
discoverable in either case. 

c. In the lower part of the temporo-sphenoidal lobe, called 
the subiculum cornu ammonis, a centre was found which caused 
a peculiar torsion of the lip and partial closure of the nostril on 
the same side. This effect is similar to that produced by the 
direct application to the nostril of a powerful odor, rendering 
it highly probable that this is the special centre for the sense 
of smell. As in the preceding sensory centres, the conclusion 
drawn from the result of electrical stimulation of this centre, 
was confirmed by its destruction, which, when effected on both 
.sides, caused the loss of smell and taste, showing that this region 
contains the centres of both these senses. Unilateral destruc- 
tion of these centres produced the most marked effects upon 
the opposite side ; bilateral destruction abolished the sensory 
function altogether. 

d. Ferrier also succeeded in locating, with considerable 
certainty, the centre of tactile sensation, which he places in the 
region of the hypocampus major and uncinate convolution. This 
region is so difficult of access with the electrodes, as to render 
it impossible to reach it safely for electrical experimentation, 
and hence destruction of this region, which is found to abolish 
tactile sensation on the opposite side of the body, is the only reli- 
able test. Ferrier finds confirmation of this being the special 
centre of tactile sensibility, in (1) indirect or mediate electrical 
excitation; (2) in clinical and pathological evidence in man, as 
given by Charcot, Raymond, Veyssiere and others, which, 
though not due to disorganization of the centres of sensation, 
interrupt the path of transmission from the organs of sense to 
the sensory centres in the cortex, i. e., the centripetal fibres 
which proceed to the hippocampal region; and (3) the impair- 
ment, or abolition of vision on the same side as the cutaneous anses- 
thesia, in which respect Ferrier's experiments on the monkey 
coincide with clinical observation, the function being abolished 
or greatly impaired on the side opposite to the lesion, as is the 
case likewise with the senses of taste and hearing, but not with 
the sense of smell, as the olfactory centre is in the hemisphere 
of the same side. Hence, as stated by Ferrier, " with the ex- 
ception of the paths of olfactory sensation, section of the pos- 



28 INTRACRANIAL DISEASES. 

terior division of the internal capsule is practically, at one 
blow, interruption of all the sensory tracts, and is equivalent 
to extirpation or disorganization of the sensory centres of the 
cortex. The differentiation of these into regions of special 
sense is simply a terminal specialization of the centripetal 
paths which radiate from the internal capsule or foot of the 
corona radiata into'the cortex." 

e. The occipital, as well as the temporo-sphenoidal lobes are 
now generally regarded as containing sensory centres, although 
partial or complete removal of them fails to show any effect 
upon the motor or sensory functions. Ferrier, how T ever, re- 
gards these lobes as specially related to the visceral sensibilities- 
He found that while their removal is without effect on any of 
the faculties of special sense, on the powers of voluntary mo- 
tion, or on the functions of respiration and circulation; and 
while their removal is a less severe operation than the re- 
moval of the frontal lobes, in which the animals retain their 
appetite and eat and drink with apparently their usual relish, 
the removal or disorganization of the occipital lobes is attended 
with a complete loss of appetite for food, although the appetite 
for drink still remains. 

8. The experiments we have described seem clearly to es- 
tablish the following facts : (1) That there is a motor zone in 
the centre of the cerebral hemispheres, embracing the central 
and posterior portions of the frontal lobes; also, that there is 
a sensory zone, embracing the temporo-sphenoidal lobe, which 
is situated between the motor area, in front, and the occipital 
lobe, behind. (2) That these zones include distinct centres, 
each of which is endowed with its special and well-defined 
function. (3) That electrical stimulation of the motor centres 
produces contraction of certain sets of muscles with which 
they stand connected, while destruction of these centres pro- 
duces paralysis of said muscles. And, (4; that electrical irri- 
tation of the sensory centres exalts their functions, while bi- 
lateral destruction of said centres abolishes their function?. 
This is as far, perhaps, as experimental physiology will enable 
us, in the, present state of our knowledge, to go in the inter- 
pretation of cortical cerebral phenomena, for, as we have seen, 
some of the phenomena are inexplicable except upon the 



SENSORY CENTRES. 29 

theory of substitution — a theory which is still a subject of 
much controversy. We shall see hereafter, however, that the 
doctrine of special and exclusive primary centres in the cere- 
bral cortex, derives very great support from anatomical, patho- 
logical and clinical considerations, which together furnish an 
amount of evidence in favor of the theory of localization that 
falls but little short of full demonstration. 

But motion and sensation are by no means the exclusive 
functions of the cerebral convolutions. Experimental and 
clinical evidences have established the fact that the anterior 
portion of the cerebral cortex is eminently psychical in its 
nature, being the special seat of volition and intelligent con- 
sciousness. The removal of the cerebrum in animals does not 
destroy the perceptive faculties of sight, hearing and taste, as 
asserted by Flourens,* nor, if the basal ganglia are left undis- 
turbed, does it permanently destroy the mechanism of coordina- 
tion of muscular movements, but the animals simply appear 
stupid, as though deprived of intelligence. Both Hitzig and 
Landoisf assert that when those portions of the cerebral 
cortex which govern the movements of the extremities, is 
excised, there is a rise in the temperature of the corresponding 
limbs, and that the elevation of temperature continues several 
months. A connection has also been observed between the 
cerebral cortex and the cardiac pulsations, a change in arterial 
pressure, dilatation of the pupils, salivation, and contraction 
of the spleen, bladder and uterus; but the true centres of some 
of these are not well determined, and there is reason to believe 
that they are really located in some other portion of the ner- 
vous system. The most important discovery, however, is that 
of Broca,| who, in the year 1861, succeeded in locating' the 
seat of intelligent language in the third convolution of the left 
anterior lobe of the brain. This discovery has since been re- 
peatedly confirmed, the most recent investigations tending, as 
I have elsewhere shown, § to prove that the special centre for 
articulate language is in, or very near, the island of Reil. 

* u Recherches experimentales sur les proprieties et les fonctions du systeme 
nerveux," Paris, 1842. 

f Virchow's " Archiv.," 1876. % Broca, Bui de la Soc. Anal, 1861. 

\ Nervous Diseases, p. 206. 



30 INTRACRANIAL DISEASES. 



CHAPTER II. 

FUNCTIONS OF THE CEREBRAL GANGLIA. 

Meynert* divides the cerebral ganglia into two principal 
parts, the ganglia of the tegmentum pedunculi, and the ganglia of 
the pes pedunculi, the former comprising the corpora quadri- 
gemina and thalamus opticus, and the latter, the corpus striatum 
and cortex of the brain. These two great parts are again con- 
nected by commissural fibres, so as to form a special gangli- 
onic system. We shall consider the two principal members of 
this system under the head of 

1. — The Basal Ganglia. 

Electrical stimulation of the corpora striata causes general 
tonic contractions of the muscles of the face, neck, trunk, and ex- 
tremities. When the irritation is confined to one of these 
ganglia, the spasms are unilateral, the flexors predominate 
over the extensor muscles, and the body is bent to the oppo- 
site side. According to Ferrier, Carville and Duret, muscular 
movements are not capable of being differentiated by the 
direct stimulation of these ganglia, as in the case of the corti- 
cal centres, although in Dr. Sanderson's experiments separate 
movements were produced after the cortical substance was re- 
moved ; but this result is referred by Ferrier to the stimulation 
of the medullary fibres connecting the cortical centres with 
corresponding centres in the corpus striatum, although these 
centres are not capable of individual excitation when the 
electrodes are applied directly to the ganglion itself. Hence 
he infers there is in the corpus striatum a combination or in- 
tegration of the various centres which are differentiated in the 
cortex. 

* Strieker's Handbook. 



FUNCTIONS OF THE CEREBRAL GANGLIA. 31 

Although Ferrier generally found the optic thalami insensi- 
ble to faradization, there was marked impairment of sensory 
function when disorganized or destroyed by the actual cautery. 
On chloroforming a monkey, he inserted a wire cautery in 
such a manner as to traverse the optic thalamus completely. 
Before the animal recovered consciousness, the left eye ap- 
peared to be permanently closed, and when, after recovery, it 
opened its right eye, the right pupil was found to be dilated. 
The right side was completely paralyzed, cutaneous sensibility 
on that side was destroyed, and the animal was apparently 
blind ; but as the medullary substance just external to the 
ganglion had been previously broken up, in an unsuccessful 
attempt to destroy the optic thalmus, it is not certain that the 
blindness in this case was not due, to some extent, to the lesion 
of the medullary fibres and cortical substance. The experi- 
ment proves, however, that both vision and cutaneous sensi- 
bility may be destroyed by an injury in and around the optic 
thalamus. Now, Veyssiere, the result of whose experiments has 
been confirmed by Carville and Duret, has established, both 
by clinical evidence and by carefully conducted experiments 
on the lower animals, the fact that section of the posterior 
part of the peduncular expansion causes hemianesthesia. 
Moreover, Tiirck, Demeaux, Bourneville, Charcot, and others, 
report cases showing that in man hemianesthesia occurs when- 
ever the corresponding regions of the internal capsule are de- 
stroyed by disease ; while Ferrier's experiments show that, as a 
rule, vision is seriously impaired, if not quite abolished, on 
the same side as the cutaneous anaesthesia, i. e., the side oppo- 
site the cerebral lesion. AVe see, also, that there is a differen- 
tiation of the paths and centres of sensation from those of 
motor impulses ; and as the motor paths are limited to the 
corpus striatum and the anterior part of the internal capsule, 
the only path remaining for the transmission of sensory im- 
pressions from the periphery to the hemispheres, as pointed 
out by Ferrier, is through the tegmentum cruris cerebri, tit e 
optic thalamus and its medullary connections with the cortex. "To 
assert," says Ferrier, " in the face of these facts, that sensation 
can still continue, notwithstanding the total destruction of the 



32 INTRACRANIAL DISEASES. 

optic thalamus, both cells and medullary fibres, is to assert 
nothing less than a physical impossibility."* 

It thus appears that the optic thalami bear the same relation 
to the sensory regions of the cortex, that the corpora striata do to 
the motor regions. The medullary fibres which converge to, 
and diverge from, the optic thalamus, are mostly distributed 
to the posterior and temporo-sphenoidal regions of the cortex, 
which, as we have seen, are special centres of sensation. 
Luysf says the body of this ganglion is made up of four sepa- 
rate ganglionic masses, (1) centre anterieur, (2) centre moyen, (3) 
centre median, and (4) centre posterieur, which are connected 
with the olfactory, optic, auditory and tactile tracts respec- 
tively, and with corresponding regions in the cortex. As the 
researches of Meynert,J however, led him to somewhat differ- 
ent conclusions, Ferrier is not disposed to give full credit to 
these results. Moreover, the theory that the optic thalamus is 
called into action in the upward transmission of sensory impres- 
sions, and that the corpus striatum is the centre through 
and by which the motor impulses are transmitted downward to 
the opposite side of the body, though in harmony with the 
evidence just adduced, is yet far from being fully demon- 
strated. For, although haemorrhage into the corpus striatum 
causes paralysis of the opposite side, instances are not want- 
ing where both ganglia have been removed without the loss of 
either sensation or motion. Moreover, while MM. Lussana 
and Lemoigne§ state that destruction of the optic thalamus 
resulted in blindness of the opposite eye, Longet,|| who suc- 
ceeded in destroying the ganglion on both sides, was unable 
to detect any impairment of vision, or any influence upon the 
movements of the pupil. At the same time, it must be ad- 
mitted that the distribution of the fibres of the crus cerebri 
are such as to point strongly to the corpora striata as motor 
centres, and to the optic thalami as presiding over sensory im- 
pressions. 

* " Functions of the Brain," p. 266. 

f " Recherches sur le Systeme Nerveux," 1865. 

% Vide, ante. 

I " Fistologia die Centri Nervosi Encefalici," 1871. 

|| " Traite de Physiologic" 



functions of the cerebral ganglia. 33 

2. The Corpora Quadrigemina. 

It is generally conceded that the corpora quadrigemina are 
the true optic ganglia, for when they are destroyed, vision is 
completely abolished, and the pupils no longer contract under 
the stimulus of light; but the experiments of Hen sen* and 
Voelkersf appear to indicate that the exact seat of the centre 
or centres controlling the function of vision, contraction of the 
pupil, and the movements of the eyeball, is situated in the 
aqueduct of Sylvius, immediately beneath the tubercula quadri- 
gemina; stimulation of the deeper portions of the nates, after 
removal of the upper, yielding more uniform results than 
before the section was made. This inference is sustained by 
the anatomical fact, that the deep origin of the third, or motor 
oculi nerve, can be traced to a grey nucleus in the floor of the 
aqueduct of Sylvius. 

Unilateral destruction of these ganglia causes blindness of 
the opposite eye; but vision remains even after the hemi- 
spheres have been removed, provided the optic ganglia are 
uninjured. This fact appears inconsistent with the results of 
Ferrier's experiments upon the angular gyrus,* in which 
vision was abolished when both gyri were destroyed; but the 
probability is that these ganglia sustain a similar relation to 
that portion of the cerebral cortex, that the basal ganglia do 
to the other cortical ceutres. 

Stimulation of the right side of the nates, according to 
Adamuk,§ causes both eyes to move to the left, and stimulation 
of the left side, to the right; in front it causes an upward, and 
behind, a downward movement of both eyes, accompanied 
with divergence or convergence of the optic axes and corre- 
sponding changes of the pupil. We thus see that the centres 
governing the movements of the eyeball and pupil are, like 
the movements themselves, closely connected with each other. 

The corpora quadrigemina have a marked influence on the 
expression of the. emotions, such as fear, terror, joy, etc. They 
also appear to be connected in some way with the function of 

* " Centbl. Med. Wiss.," 187C. J Vide ante, op. cit. . 

f " Archiv. f. Ophthalmol./' 1878. | " Ctntbl. Med. Wiss.," 1870. 

3 



34 INTRACRANIAL DISEASES. 

coordination of muscular movements, faradization of these bodies 
producing complex movements of all the voluntary muscles, 
especially of those concerned in progression and the mainten- 
ance of the normal attitude. This is in harmony with the dis- 
covery of Flourens,* that the removal of the corpora quadri- 
gemina impaired the power of muscular coordination, and 
sustains the belief that the mechanism of coordination is of 
a complex character, involving not only the cerebellum, but 
the tubercula quadrigemina, pons Varolii, and other ganglia. 
Faradization of the corpora quadrigemina, in animals, causes 
them to moan and utter peculiar cries; a fact that has led 
some to infer that the protracted moaning which is sometimes 
heard during attacks of epilepsy, is owing to irritation of these 
ganglia, just as the shrill cry that frequently ushers in the 
convulsive stage of that disease, points to irritation of the 
medulla oblongata. 

3. The Crura Cerebri and Pons Varolii. 

The crura cerebri and pons Varolii, which form the greater 
portion of the meso-cephalon, are abundantly supplied with 
grey matter, showing that they are endowed with important 
ganglionic functions. The crura, as they diverge from each 
other in their upward course, are traversed by the third, or 
motor oculi nerves, the deep origin of which is just below the 
corpora quadrigemina. That some of the nerve fibres decus- 
sate between these points, is evident from the fact that de- 
struction of one crus cerebri causes paralysis of motion and sen- 
sation on the opposite side of the body, and paralysis of the motor 
oculi nerve on the same side. Again, some of the roots of the 
facial nerve, which makes its exit from the side of the medulla 
oblongata, can be traced as far as the floor of the fourth ven- 
tricle, while others spring from the upper border of the pons 
Varolii. As the latter are below the point of decussation, we 
find that injury of the pons causes complete facial paralysis on 
the same side, and paralysis of the extremities on the opposite side. 
Moreover, the fibres of the pons decussate in such a manner, 

* Op. cit., 1845. 



FUNCTIONS OF THE CEREBRAL GANGLIA. 35 

owing to the separate origins of the roots above mentioned, 
that both sides of the face may be paralyzed and only one side 
of the body. 

It appears from various experiments made upon the pons 
Varolii, that automatic movements, especially those governing 
station and progression, are regulated by it, independent of the 
action of the hemispheres. A somewhat similar function of 
the pons applies to the sensation of pain, which appears from 
the experiments of Longet* to be perceived by it even after the 
removal of both the hemispheres and the basal ganglia. We 
are justified, therefore, in regarding the pons Varolii as the 
ganglionic centre by w T hich peripheral impressions are first 
converted into conscious sensations, and in which the volun- 
tary impulses which stimulate the muscles to contraction, 
originate. This ganglion has also an important influence on 
articulation, for although intelligent speech does not seem to 
suffer from disease seated in this centre, yet, owing to paresis 
and incoordination of the muscles concerned in the formation 
of sounds, the pronunciation of words is rendered more or less 
clumsy and unintelligible. 

4. The Cerebellum. 

Although the most opposite opinions have at times been en- 
tertained regarding the functions of this organ, and although 
its physiological action cannot even yet be considered as fully 
settled, no fact perhaps is better established, than that the 
cerebellum forms an essential part of the central mechanism 
by which coordination of muscular movements is effected. The 
fact is likewise well established, that this ganglion is capable 
of exercising no truly mental function, either of sensation, volition, 
emotion, or intellect. The experiments of Flourensf on pigeons, 
the results of which have been repeatedly confirmed, prove 
conclusively that the removal of the cerebellum, while not 
impairing the functions of sensation, volition and intelligence, 
causes in all cases loss of the powers of coordination. Au- 

* Op. cit. 

f "Kecherches Experimental es sur les Proprietes et les Fonctious du Systeme 
Nerveux " 2d ed., 1842. 



36 INTRACRANIAL DISEASES. 

thorities differ somewhat, however, as to the duration of these 
effects, Flourens asserting that the removal of the cerebellum 
causes permanent disorders of equilibrium, while the experi- 
ments of Dalton, Wagner, Mitchell and others, appear to show 
that recovery may take place after the removal or destruction 
of the greater portion of the organ. 

The intimate connections of the cerebellum w T ith the other 
portions of the encephalic mass, will serve to explain, to some 
extent, the complex movements and other phenomena pro- 
duced by stimulation or lesion of different parts of the organ. 
Thus, destruction of the anterior part of the middle lobe causes a 
tendency to fa 11 forward, while irritation of the same part, either 
by faradization or by disease, excites such muscular move- 
ments as would tend to counteract that effect. Again, destruc- 
tion of the posterior part of the middle lobe induces a tendency 
to fall backwards, and of the lateral lobes to fall sideways, while 
stimulation of these parts provokes those movements which 
are calculated to counteract such tendency, such as movements 
of the eyes in different directions, contraction of the pupil, and 
the peculiar movements of the head and limbs. These forms 
of vertigo are so similar to those which occur in " Meniere's 
disease," or auditory vertigo, as to lead some physiologists to 
infer that there is some sort of connection between the semi- 
circular canals of the ear and the cerebellum.* Few, however, 
are willing to accept such symptoms as positive evidence of 
the irritation of this centre, owing to the proximity of other 
points the irritation of which would be liable to excite similar 
symptoms, such as the corpora quadrigemina, the points of 
origin of the third, fourth and sixth nerves, and the different 
nuclei of the fourth ventricle. Moreover, as we have seen, the 
functions of cerebellar coordination cannot be completely sep- 
arated from those of the optic lobes and pons Varolii, these 
parts, according to Ferrier, forming a combined mechanism 
incapable of being separated without producing a general de- 
rangement of function. 

The influence of the cerebellum over peristaltic movements 

* See Vertigo, Part II. 



FUNCTIONS OF THE CEREBRAL GANGLIA. 37 

in the oesophagus and stomach, has been pointed out by Budge; 
and Schiff mentions a very acute form of intestinal inflamma- 
tion, accompanied with haemorrhage, which resulted from in- 
juries to the peduncles. 

Priapism has occasionally been observed in haemorrhage of 
the middle lobe of the cerebellum, which has led some to re- 
gard this organ as the centre of the sexual appetite, but the 
effect mentioned was probably due to pressure of the clot upon 
the posterior surface of the medulla oblongata and pons Varolii. 
In fact, the centre of the sexual appetite appears from the 
most recent experiments to be located, not in the cerebellum, 
but in the lumbar region of the spinal cord. The relation of 
the kidneys, however, to the cerebellum, has been shown by 
Eckhard,* who found that galvanism 'of this organ produced 
diabetes. 



* << 



Beitrage," 1878. 



38 INTRACRANIAL DISEASES. 



CHAPTER III. 

FUNCTIONS OF THE BULB. 

Owing to the fact that the medulla oblongata connects the 
spinal cord with the cerebrum, its functions are extremely 
varied and complicated. Thus : 

1. As the centre from which are distributed most of the 
fibres which pass to the other intracranial ganglia, it receives 
and transmits both the sensory impressions and the motor im- 
pulses that pass to and from the cerebrum. 

2. Its motor fibres decussate in the anterior pyramids, in 
such a manner as to connect each half of the brain with the 
opposite half of the body, producing in cases of injury and 
disease of the cerebrum the phenomena of crossed paralysis. 

3. It gives origin to numerous important nerves, through 
which, in connection with their sympathetic relations, are 
manifested phenomena of reflex coordination originating in the 
following centres : 

a. The respiratory centre, the exact seat of which is in the 
apex of the fourth ventricle, at the point of the calamus scrip- 
torius. This centre has been termed by Flourens the nosud 
vital, or vital knot, because any considerable injury at this 
point causes immediate death. Faradization or morbid stimu- 
lation of this centre produces sudden tonic contraction of the 
respiratory muscles of the neck, chest, and diaphragm. Epi- 
leptic and other convulsions generally arise from irritation of 
the medulla oblongata, as well as the sharp cry which ushers 
in the convulsive seizure. 

b. The cardio-inhibitory centre, by which the heart is held 
under control, in obedience to sensory impressions transmitted 
to the medulla oblongata by means of sensory nerves. This 



FUNCTIONS OF THE BULB. 39 

centre does not cause the regular pulsations of the heart, which 
are under the influence of the motor ganglia in the cardiac sub- 
stance itself; but its movements are inhibited, or arrested in 
diastole, by impressions carried to the medulla oblongata. If 
the mesentery of the frog be exposed and slightly tapped, the 
heart will immediately cease to beat, but will soon resume its 
rythmical action. This shows the responsive action of the 
medulla to afferent sensory impulses, and also its inhibitory 
influence upon the heart. The rythmical action of the heart 
is under a two-fold nervous influence. One, the inhibitory or 
restraining influence, is exercised through the pneumogastric 
nerve, section of which accelerates the pulsations until they be- 
come too rapid to be counted ; on the contrary, if the inhibi- 
tory action is called into full play by means of faradization, 
the heart will stand still during diastole. The accelerating 
action takes place through the sympathetic fibres proceeding from 
the medulla, and which reach the heart through the lower 
cervical and first dorsal ganglia of the sympathetic nerve. 

c. The vaso-motor centre, which regulates the size of the blood- 
vessels. Dittmer* locates this centre in the lateral columns, 
after the fibres have been given off to the anterior pyramids ; 
Clark places it near to the origin of the facial nerve ; whilst 
others limit it to the floor of the fourth ventricle. Stimulation 
of this centre causes contraction of the blood-vessels, whilst section 
of it paralyzes them. 

d. The emotional centre, which, acting through the facial 
nerve, gives expression to the countenance. Stimulation of 
this centre in the medulla oblongata produces spasm of the 
facial muscles, such as are often observed in convulsions arising 
from irritation of this portion of the nervous system. 

e. The centre for deglutition, which harmonizes the action of 
the muscles of the lips, tongue, palate, and pharynx in the act 
of swallowing, more particularly in the last two stages of that 
act, or from the time the food passes the isthmus of the fauces. 

/. The cesophagal and gastric centre, for regulating the move- 
ments of the oesophagus and stomach, and controlling the 
mechanism of the act of vomiting. 

*Lud wig's " Arbeiten," 1873. 



40 INTRACRANIAL DISEASES. 

g. The salivary centre, which regulates the secretion of saliva, 
and possibly, also, that of the pancreatic fluid. The increased 
flow of saliva consequent upon the use of aromatic substances, 
such as ginger, cloves, etc., is due to afferent impulses sent 
through the gustatory branch of the fifth cranial nerve to the 
medulla oblongata, whence the efferent impulse is transmitted 
through the chorda tympani branch of the facial nerve. 

h. The centre for articulate speech, which coordinates the move- 
ments of the lips, tongue, and palate in the act of speak- 
ing. This act is a complex one, requiring two sets of nervous 
influences, one acting through the pneumogastric and spinal ac- 
cessory nerves for respiration and phonation, and the other for 
lingual and labial movements through the hypoglossus and portio 
dura, which act upon the muscles controlling the movements 
of the tongue, lips and palate. The nuclei of these nerves are 
not only situated close together, in pairs, but are so connected 
by commissural fibres extending from one side to the other, as 
to insure a simultaneous action of the muscles of articulation, 
even w T hen the motor impulse is unilateral. 

i. Finally, the medulla oblongata contains a diabetic centre, 
which, when irritated, produces a saccharine state of the urine. 
Experiments upon rabbits show that, when the animals are in 
good condition, a considerable amount of sugar is thus secreted, 
within an hour or two after the experiment is performed.* 

j. The existence of distinct centres of reflex coordination in 
the medulla oblongata, which have not only been clearly de- 
monstrated upon animals, but which, from pathological and 
anatomical considerations, are known also to exist in man, 
render it highly probable that the medulla is a general centre 
for the coordination of muscular movements, some of the special 
forms of which we have found to be possessed by the upper gan- 
glia of the cerebellum, corpora quadrigemina, and pons Varolii. 

*Ranney's Applied Anat.ofthe Nerv. Sys., 1881. 



CEREBRAL LESIONS. . 41 



SECTION II. 

REGIONAL DIAGNOSIS IN BRAIN DISEASES. 



CHAPTER I. 

CEREBKAL LESIONS. 



We have seen that the investigations of modern physiolo- 
gists prove most conclusively that the various groups of mus- 
cles are under the direct control of different portions of the 
grey substance of the cerebral cortex, as well as of the related 
ganglia below ; for although lesions apparently contradictory 
of these results have from time to time been brought forward, 
Ferrier* has shown that in most cases the seeming contradic- 
tions are capable, not only of being reconciled with the theory 
of cortical localization, but oftentimes of confirming it in the 
most remarkable manner. This is especially true of lesions 
the effects of which are limited to particular areas, instead of 
being diffused, by pressure or otherwise, as in the case of 
tumors, where the effects are liable to be felt at a distance from 
the seat of lesion, and thus render the results more or less com- 
plex. Ferrierf enumerates the following lesions as being of 
special value in establishing the theory of localization of brain 
diseases, viz., "cases of wounds, laceration, or loss of substance, 
with various forms of chronic degeneration, such as atrophy, 
necrosis, etc., and the results of haemorrhage, inflammation, and 
the like, which, though at first complex, subside into local 

'■- ''Localization of Cerelral Diseases," J 879. 
f Op. cit. 



42 INTRACRANIAL DISEASES. 

lesions, such as softenings, cysts, and abscesses; or, in general, 
all lesions which exclude meningo-encephalitis, mechanical 
compression, or general cerebral disturbance." This distinction 
is all that is necessary, so far as regional diagnosis is concerned, 
whilst the diagnosis of the nature of the lesion will depend on 
other characters, such as the general symptoms, the mode of 
onset, and the various special features by which we are enabled 
to individualize the disease. 

At the same time, however, it should be borne in mind that, 
so far as our present knowledge extends, there are no known 
systemic lesions in the brain.* The term systemic was applied 
by Vulpian to those lesions which are systemically circumscribed, 
that is, such as do not extend beyond the limits of certain 
clearly defined regions ; as in the spinal cord, where there are 
lesions limited to the anterior cornua of the grey substance, to 
the lateral fasciculi, and to the posterior columns. But there 
are no such systemic lesions known to occur in the brain ; no 
lesions invariably limited, for example, to the various portions 
of the cortex, to the thalami optici, or to the different ganglia 
of the corpora striata.f Not th^t anatomical demarcations of 
disease do not exist in the encephalon, but that they are rela- 
tively rare, and, to all appearances, wholly accidental. The 
explanation, according to Charcot, lies in the fact that the 
brain, unlike the other portions of the cerebro-spinal axis, is 
under the control of the vascular system ; or, in other words, 
the arteries, veins, and capillaries " command the situation." 
For example, the most constant anatomical lesion of the brain 
at present known is that of Broca, confined chiefly to the third 
left frontal convolution, or the island of Reil ; yet this is no ex- 
ception to the rule, since aphasia, as we have elsewhere shown,J 
is found to depend upon obstruction of the middle cerebral 
artery or its branches. Hence, Charcot calls especial attention 
to the importance of vascular ruptures and the consequent 
haemorrhage in the cerebral centres, and to the predominant 

* Charcot, " Localization in Diseases of the Brain," 1878. 

f I. e., the lenticular and cordated nuclei or ganglia, into which the corpora striata 
are now divided. 

X See Nervous Diseases, p. 218. 



CEREBRAL LESIONS. 43 

influence of vascular obliteration by thrombosis and embolism, 
which result in extravasation, followed by partial softening of 
the brain. 

Another fact that should be carefully borne in mind is, that 
although the brain is undoubtedly the organ of the mind, it 
may be greatly diseased without producing any very obvious 
mental disorder. On the other hand, well-marked mental de- 
rangement may occur without any characteristic morbid ap- 
pearances showing themselves after death ; and even in those 
cases where morbid conditions are revealed by post-mortem 
examination, such as the various forms of degeneration in the 
vessels, nerve-cells, neuroglia, etc., there has not yet been dis- 
covered any definite relation between the locality of the lesion 
and the symptoms observed. Hence, so far as certain faculties 
of the mind are concerned — the affections, desires, emotions, 
etc. — there is at present no well-marked localization of function 
— one sound hemisphere being sufficient for the performance 
of every mental function. It by no means follows, however, 
that there are no special centres of mental action, and therefore 
that there can be no differentiation or localization of mental 
diseases. Indeed, so far as the general seat of the intellect is 
concerned, it may be said to be already well established. Vo- 
lition, also, when expressed in action, is differentiated both by 
elevation of temperature* of the cerebral centre and by the motor 
phenomena. Mental symptoms, however, are not only fre- 
quently difficult of appreciation, but we are not yet in posses- 
sion of the requisite criteria for determining with certainty 
whether the mind has, or has not, altogether escaped damage 
in every case attended with cerebral lesions. Moreover, the 
cases of bilateral cerebral lesions are comparatively few, and it 
is only in such, so far as diagnosis is concerned, that the men- 
tal symptoms or deficiencies can be said to have any weight. 
These considerations, however, only show the difficulties in the 
way of determining the localization of mental diseases and 
functions, and not the absolute non-existence of special centres 
of mental action. Strict research, therefore, may yet determine 
anatomical localizations of mental affections, but at present we 

* Prize Essay of 1880, Archiv. % of Med., New York, April, 1880. 



44 INTRACRANIAL DISEASES. 

have no definite knowledge on which to base a regional diag- 
nosis in diseases of this charactor. 

The following general statements, based chiefly upon the 
observations of Ferrier, Charcot and Nothnagel, embrace re- 
sults which have received clinical verification, and can gener- 
ally be relied upon in the regional diagnosis of cortical lesions: 

1. Although no exact localization of mental disturbances can 
yet be made, such derangements indicate, in general, disease 
of the surface of the brain, that is, of the grey substance of which 
the cerebral convolutions are chiefly composed. 

2. Disease of the cortex may exist in a latent form, that is, 
without giving rise to decided symptoms ; hence, the absence 
of symptoms is no proof that the grey substance of the convo- 
lutions is not affected by disease. 

3. Diseases within the motor area, however, generally give 
rise to symptoms, either of a positive or negative character. 

4. Lesions of the cortex outside of the motor area will pro- 
duce no symptoms unless the cerebral membranes are in- 
volved, in which case there may be convulsions, and possibly, 
headache; these symptoms being the result of irritation of the 
motor and sensory areas of the cortex. 

5. At present, sensory disturbances have but little value in the 
diagnosis of cortical lesions of the brain. Unilateral disturb- 
ances of vision sometimes occur, but so far they have only 
been observed in connection with diffused cortical lesions, 
such as progressive paralysis, cysticercus, etc., and are of no 
importance in regional diagnosis. As for hemiopia, it is only 
in cases where the symptom is developed suddenly, and is 
purely of a subjective character, that the existence of a cortical 
lesion can be suspected. If such a lesion exist, it will probably 
be located in the occipital lobe. 

6. Aphasic or dysphasic symptoms indicate that the lesion 
involves one of the following localities, which are given in the 
order of their frequency : (a) the third left frontal convolution ; 
(b) the island of Reil ; (c) the white substance between the third 
left frontal convolution and the base of the cerebrum. 

7. Lesions of the left parietal lobe, and more particularly of 
the first temporal convolution, are liable to produce word-deafness. 



CEEEBRAL LESIONS. 45 

8. Cortical lesions generally give rise to motor derange- 
ments, the character of which is sometimes sufficiently diag- 
nostic to indicate the seat of the disease. 

9. The possible implication of the corpus striatum will often 
render the diagnosis of cortical lesions more or less doubtful, 
especially when they take the form of a simple hemiplegia, 
such as generally results from a lesion of that ganglion. In 
such cases no positive diagnosis can be made. Other associ- 
ated symptoms, such as aphasia, may render the diagnosis 
more probable, but even then the aphasic or other cortical 
symptoms may be connected with a corpus striatum lesion. 

10. Lesions of the cortex resulting in actual destruction of the 
grey matter of the motor area, are generally followed by pa- 
ralysis ; whilst irritative lesions of the cortex usually give rise to 
either partial or general convulsions. 

11. Paralyses arising from lesions of the cortex generally in- 
dicate monoplegias, partial hemiplegias, paralyses of the hypo- 
glossal, facial and brachial nerves, or of the nerves of the face and 
arm, or arm and leg ; the leg alone is rarely involved. 

12. Paralysis of motion, when confined entirely, or even 
chiefly, to the upper extremity, indicates not only that the 
lesion is located on the opposite side of the brain, but that it is 
probably confined to, or involves, the ascending convolutions 
of the parietal or frontal lobes. 

13. When the paralysis is confined chiefly or exclusively to 
the muscles of the lower extremity, and is of intracranial 
origin, the lesion probably involves the convolutions at the 
upper extremity of the fissure of Rolando. 

14. Monoplegias, even when of intracranial origin, do not 
indicate with absolute certainty, but only with great proba- 
bility, the existence of a cortical lesion. 

15. The associated symptoms are often of very great import- 
ance in determining the diagnosis. Thus, if with paralysis 
of the extremities, there is also paralysis of the facial and 
hypoglossal nerves, and especially if ptosis is also present, the 
paralysis is probably due to a cortical lesion. On the other 
hand, if the motor hemiplegia is associated with marked dis- 
turbances of sensibility, it indicates either that the lesion does 



46 INTRACRANIAL DISEASES. 

not involve the cortex, or if it does, that the lesion is extensive, 
and extends deeply into the white substance below. 

16. Motor irritative symptoms arising from lesions of the 
cortex indicate that the seat of lesion is probably in the ascend- 
ing frontal or postero-parietal convolutions, or in the paracentral 
lobule. 

17. Irritative symptoms take the form of partial or general con- 
vulsions, which may either precede or follow paralysis of the 
affected muscles. If partial, they may occur either as the re- 
sult of haemorrhage or softening, or the development of a tumor. 
If general, they will be of an epileptiform character, the initial 
spasms always recurring in the same group or groups of mus- 
cles in the face or extremity, and always subsequent to an 
existing paralysis. 

18. The paralysis which follows motor disturbances resulting 
from cortical irritation, is generally of the transient variety, but 
it may be permanent. 

19. Motor paralysis, due to destructive lesions of the grey 
matter of the cortex, occurs on the side of the body opposite 
the seat of the disease, and is generally permanent. 

20. It is probable that only those destructive lesions of the 
cortex w T hich implicate the subjacent white substance, are 
capable of producing motor paralysis of the opposite side of 
the body; for no symptom of importance results from lesions 
of the centrum ovale, except such as occurs in the anterior and 
posterior central regions, namely, motor paralysis of the oppo- 
site side, similar to what is caused by lesions of the cortex and 
corpus striatum. 

21. When, after an attack of hemiplegia from destructive 
lesions of the cortex, the paralyzed muscles become rigid, it 
indicates that a secondary degeneration of the nerve-fibres has 
set in, and is progressing downward along the spinal cord. 
This is most marked in cases where the lesion is seated in the 
paracentral lobule, but applies to some extent to the entire 
motor area of the cortex. 



LESIONS OF THE BASAL GANGLIA. 47 



CHAPTER II. 

LESIONS OF THE BASAL GANGLIA. 

Charcot and Nothnagel have recently made the basal gan- 
glia the subject of special investigation, with the view of 
affording a satisfactory explanation of the clinical phenomena 
exhibited by the various lesions of these important organs; 
and as the results which they have reached are of great prac- 
tical interest and value, we shall present a synopsis of them 
nearly in their own words. 

As before stated, Charcot bases his views of cerebral local- 
ization chiefly upon the anatomy of the cerebral circulation. 

The following are his principal conclusions : 

1. The symptoms which arise from softening of the entire 
region occupied by the basal ganglia, are those of cerebral hemi- 
plegia accompanied with cerebral hemianesthesia. We are not 
able to recognize the special symptoms which belong to de- 
struction of the thalami optici, the caudated or the lenticu- 
lar ganglia,* and still less, the various segments. It is 
possible, however, in some cases, to make a regional diag- 
nosis, based upon the arterial distribution ; as, for example, 
when the lesion affects all, or nearly all, of the territory of the 
lenticulo-striated arteries, or that of the lenticulo-optic arteries. 
In the latter case the symptoms of herniansesthesia are present, 
whilst in the former they are absent. 

2. In lesions confined to either one of these ganglia, and 
where the internal capsule is not involved, it is impossible to 
distinguish, during life, a lesion limited to the lenticular 
ganglion from one confined to the caudated ganglion; and 

* The ventricular and extraventricular portions of the corpus striatum are now 
known as the caudated nucleus or ganglion, and the lenticular nucleus or ganglion. 



48 INTRACRANIAL DISEASES. 

lesions of the thalamus opticus generally confound themselves 
clinically with those produced in the two compartments of the 
corpus striatum. 

3. The symptoms which accompany lesions of these ganglia 
are those of common cerebral hemiplegia. This form of cerebral 
hemiplegia may be called central to distinguish it from cortical 
central hemiplegia. 

4. Paralysis dependent upon lesions of these ganglia is gener- 
ally of motion only ; to which, however, disturbances of sensa- 
tion such as belong to central hemiansesthesia are sometimes 
added. 

5. Hemiplegia arising from lesions confined strictly to these 
ganglia, is generally transitory, passing, lightly marked, and, 
in any case, is at first comparatively benign. This arises, 
doubtless, from the fact that these ganglia are scarcely ever 
affected in their totality. 

6. If the internal capsule be involved, whether the grey sub- 
stance of the ganglia be implicated or not, the hemiplegia is 
of a very marked and persistent character. Thus, even w T hen 
very circumscribed, and especially when seated low down by 
the side of the peduncle, these lesions produce a motor pa- 
ralysis almost necessarily accompanied by late contractions ; a 
symptom of bad augury in these cases, because as a rule it in- 
dicates that the paralysis will be permanent. 

7. If the lesion occupies any part of the anterior two-thirds of 
the capsule, that is, the region where the white tract separates 
the anterior extremity of the lenticular ganglion from the 
head of the caudated ganglion, and which belongs to the field 
of the lenticulo- striated artery, the paralysis will be exclusively 
that of motion; there will be no durable trouble of sensation. 

8. But, on the contrary, if the lesion should extend to the 
posterior third of the capsule, in that region where it passes be- 
tween the posterior extremity of the lenticular ganglion and 
the thalamus opticus, the presence of cerebral hemianesthesia 
would be almost certain. 

9. Most frequently the lesion extends to several parts, and 
paralysis of sensation will be accompanied with a more or less 
marked motor hemiplegia. 



LESIONS OF THE BASAL GANGLIA. 49 

10. But it may happen that cerebral hemianesthesia will occur 
alone, at least as a permanent phenomenon ; as, for example, in 
those cases where the most distant parts, the most posterior 
portion of the internal capsule, would alone be definitely 
altered. 

11. The above observations are based upon truly destructive 
lesions of the internal capsule, such as lacerations or necrosis, 
producing irreparable loss of substance. But the internal cap- 
sule may be only indirectly involved, as where one of the grey 
ganglia, in case of interstitial haemorrhage, may be so distended 
as to compress the nerve-fibres that compose the internal cap- 
sule, and so suspend their functions. In this case the paralysis 
would always be temporary, unless the compression was the 
result of a tumor. 

12. The distinction just made should be carefully borne in 
mind, as the error has often been committed of attributing cer- 
tain symptoms to destruction of some one of the grey ganglia, 
as the thalmus opticus, or the corpus striatum, which were 
only the result of a neighboring accident, and the incidental 
compression of the internal capsule. 

13. The thalami optici are not, as commonly supposed, the 
seat of common sensation, as is shown by the fact that where a 
hsemorrhagic lesion of the posterior tract of the thalamus opti- 
cus produced, in the first instance — that is, when conditions of 
pressure existed — sensitive and sensorial disturbances, which 
disturbances cease in the later stage, that is, from the date 
when re-absorption removes the pressure from the posterior or 
lenticulo-optic region of the internal capsule. 

14. As concerns the region of the basal ganglia, it is the par- 
ticipation or non-participation of the anterior or posterior re- 
gions of the internal capsule which determines the situation 
and gives significancy to the symptoms. 

Nothnagel,* whose observations on the basal ganglia corre- 
spond with those of Charcot, adds also the following : 

15. The motor hemiplegia resulting from stationary destruc- 
tive lesions of the corpora striata, affects constantly both ex- 

* " Topi^clie Diagnostik der Gehirnkrankheiten; eine klinische Studie," Ber- 
lin, 1879. 



50 INTRACRANIAL DISEASES. 

tremities of one side, and the inferior branch of the facial 
nerve. Usually, also, the muscles of the trunk are rendered 
paretic. The hypoglossal nerve is either not at all, or only in 
the beginning affected, and seldom permanently. It is rarely 
the case that the extremities or the facial nerve are separately 
involved. 

16. When hemianesthesia is an accompaniment of corpus 
striatum hemiplegia, it is sometimes characterized by the fact 
that, along with the cutaneous anaesthesia the nerves of special 
sense — sight, hearing, taste, and smell — on the corresponding 
side are affected ; but this is not the general rule, as the con- 
dition is usually confined to the skin. 

17. The existence of hemianesthesia indicates the implica- 
tion of the most posterior part of the internal capsule, with the 
contiguous part of the corona radiata; nevertheless, lesions 
may exist in the posterior part of the internal capsule, between 
the lenticular nucleus and the optic thalamus, without giving 
rise to anaesthesia. 

18. In most cases, the hemiplegia and the hemianesthesia 
exist together ; it is only occasionally that the hemiplegia dis- 
appears and the anaesthesia remains. 

19. When the posterior portion of the internal capsule is in- 
volved, disturbances of a vaso-motor character occasionally 
occur in the paralyzed parts, such as increased temperature, 
redness, etc. 

20. Although hemichorea frequently occurs in conjunction 
with hemianesthesia, its relations to the corpus striatum can- 
not at present be accurately determined. 

21. Thalamic lesions cannot give rise to motor paralysis. 
On the contrary, when paralysis exists we must suppose other 
parts to be involved, even if the optic thalamus should be the 
principal seat of the lesion. 

22. The same is also true of sensory paralysis. We are not 
warranted in diagnosticating the existence of a lesion of the 
optic thalamus, even though the relations which exist between 
injuries of the part of the internal capsule near the thalamus 
and sensibility, are such as to lead us to conclude that the 
lesion is situated near the thalamus, or in it, in such a manner 



LESIONS OF THE BASAL GANGLIA. . 51 

that the internal capsule is also implicated. This is true, also, 
of the vaso-motor tracts. 

23. Crossed amhlyopia or homonyomous hemiopia may occur 
through lesion of the posterior third of the optic thalamus, but 
which of the two conditions exist in these cases cannot, at 
present, be determined with certainty. Such visual disturb- 
ances, however, do not indicate the existence of thalamic 
lesions with any degree of positiveness, as they may occur with 
other localized lesions of the brain, such as those of the occipi- 
tal lobes, the optic tracts, and the corpora quadrigemina. 

24. Such irritative motor disturbances as hemichorea, athe- 
tosis, and unilateral tremor, may possibly be due to lesions of 
the optic thalamus ; but even if the fact were definitely estab- 
lished, they would be of very little diagnostic value, as they 
may also occur in lesions of other parts. 

25. It is also possible that disturbances of the muscular 
sense, and disorders of psycho-motor reflex actions, are indica- 
tions of thalamic lesions ; but further observations and investi- 
gations are necessary to settle these points. 

26. A lesion of the optic thalamus may, perhaps, under the 
most favorable combination of circumstances, be diagnosticated, 
provided the conditions mentioned under the last three sec- 
tions be present, but even then there would be more or less un- 
certainty about it. 

27. The symptoms resulting from lesions of the tubercula 
quadrigemina are sometimes hardly noticeable, and at others 
exceedingly ambiguous ; so much so, in fact, as to render the 
diagnosis of diseases of these organs very difficult and uncertain. 

28. Lesions of the nates are generally, but not always, accom- 
panied with diminution of the sense of sight, or even blind- 
ness. This symptom, however, is too ambiguous to be neces- 
sarily referred to lesion of the corpora quadrigemina, unless it 
is of sudden development, and associated with engorged pa- 
pilla, optic neuritis, and optic atrophy. 

29. Lesions of the testes are usually accompanied with para- 
lysis or paresis of the oculo-motor nerve, but neither the pres- 
ence or the absence of this symptom is an unfailing guide for 
diagnosis. 



52 INTRACRANIAL DISEASES. 

30. When a unilateral paralysis of the oculo-motorius arises 
from a bilateral lesion, and is unaccompanied with alternate 
paralysis of the extremities, the corpora quadrigemina are prob- 
ably the organs involved. 

31. Conversely, bilateral implication of the motores oculorum 
appears to be sometimes due to a unilateral lesion of the cor- 
pora quadrigemina 

32. Lesions of the nates appear to arrest the reactions of the 
pupil ; though nothing exact is known on this subject. 

33. It appears that disturbances of equilibrium and coordi- 
nation may result from lesions of the testes, similar to those 
arising from disease of the cerebellum. 



LESIONS OF THE CEREBELLUM. 53 



CHAPTER III. 

LESIONS OF THE CEREBELLUM. 

Owing to the great diversity and variableness of the symp- 
toms, the diagnosis of cerebellar diseases is extremely difficult 
and uncertain. Moreover, they may exist in a latent form, 
and therefore be incapable of being diagnosticated. This is 
particularly the case where the lesions are of a destructive 
character, and are confined to one hemisphere; whereas, if 
only a single lobe is involved, or the lesions are of slight ex- 
tent, the symptoms, though generally more characteristic, are 
at the same time more variable and more complicated. This 
will appear if we pass in review the symptoms belonging to 
the different regions of the organ. 

Paralysis of the opposite arm and leg is frequently met with 
in lesions of the lateral hemispheres of the cerebellum, but is 
generally more marked in the leg than in the arm, and is also 
less pronounced than in the more ordinan T forms of hemi- 
plegia, being usually absent from the face, and not accom- 
panied by much diminution of sensibility. Paralysis caused 
by superficial cerebral lesions may also be absent from the 
face, but it differs from cerebellar paralysis in being more 
marked in the arm than in the leg. Consciousness is seldom 
lost in lesions of this part, unless the injur}?" is sudden and the 
lesion extensive. Vomiting is perhaps more frequently met 
with in cerebellar than in cerebral lesions; and intense par- 
oxysms of pain are frequently complained of, especially in the 
occipital region. Slight tonic contractions of the facial and 
ocular muscles may occur, accompanied with more or less ri- 
gidity of the neck and of the paralyzed limbs ; but the move- 
ments of the tongue are not generally interfered with, nor is 
there usually any difficulty in articulation or deglutition. 



54 INTRACRANIAL DISEASES. 

If the superior peduncles, which are in close anatomical re- 
lation with the corpora quadrigemina, are affected by the 
lesion, amaurosis may set in; but there is generally no mental 
disturbance or impairment, though there may be slight intel- 
lectual torpor or dulness, and perhaps some drowsiness. 

But the symptoms resulting from lesions in one lateral 
hemisphere of the cerebellum are often much less pronounced, 
there being perhaps no paralysis, but simply a paretic con- 
dition, characterized by an unsteadiness or incoordination of 
movement, or what is called a titubating gait. This muscular 
weakness, which is generally more marked in the legs than in 
the arms, is sometimes so great as to render the patient quite 
unable to walk or even to stand. 

Lesions of the middle lobe of the cerebellum are less fre- 
quently attended w T ith manifest symptoms than are those of 
the lateral hemispheres. Bastion* says "that in almost all the 
cases of disease of the cerebellum in which excitation of the 
genital functions has been noted, the lesion has been situated 
in the middle lobe. Symptoms of this type have, indeed, been 
observed in about one-third of the recorded cases of disease of 
the median lobe of the cerebellum. In both sexes there has 
appeared to be an increase in sexual desires, and in male 
patients there have been frequent erections, with or without 
seminal emissions. Such symptoms in connection with lesions 
of this part have all the more significance because they do not 
present themselves where only the lateral lobes of the cere- 
bellum are involved. With the limitation thus indicated, 
therefore, there would appear to be some foundation for the 
old phrenulogical doctrine as to the function of the cerebellum." 

If the lesion of the middle lobe be a large one, vision may 
be more or less impaired, in consequence of the irritation or 
pressure exerted by it upon the corpora quadrigemina through 
the superior cerebellar peduncles. 

Lesions of the middle peduncle of the cerebellum give rise 
to symptoms similar to those produced in animals by section 
of its fibres, namely, rotation in one uniform direction — i. e., 

* "Paralysis from Brain Disease," 1875. 



LESIONS OF THE CEREBELLUM. 55 

from the sound towards the injured side — about the longitu- 
dinal axis of the body, with a deviation downwards and in- 
wards of the eye on the injured side, whilst that of the sound 
side is directed upwards and outwards. Vulpian explains 
these phenomena by supposing that there is in these cases an 
interruption of motor power from the muscles of the side of 
the body corresponding with the lesion, thus unbalancing the 
action of those of the opposite side. 

In order to understand the effect of lesions existing either 
here, or where the root of the peduncle is implicated in the 
substance of the lateral hemisphere of the cerebellum, it should 
be remembered that the fibres of the middle cerebellar pedun- 
cles decussate in the pons Varolii. Hence, if any paralysis is 
produced, it should be sought for on the same, and not on the 
opposite side of the body. 

The following summary and estimate of cerebellar symp- 
toms is based chiefly upon the observations of Nothnagel.* 

1. The most characteristic symptoms of cerebellar affections 
are incoordination, a titubating gait, and intense vertigo. 
These symptoms are, however, met with in other brain dis- 
eases, and are therefore not pathognomonic. The diagnosis of 
cerebellar disease can only be made by taking into considera- 
tion all the phenomena, positive and negative. 

2. Incoordination and vertigo, when dependent on cere- 
bellar disease, always denote implication of the middle lobe, 
either by its being the primary seat of the lesion, or by its 
functions being disturbed through pressure. 

3. These symptoms are so important, that whatever other 
grounds we may have for suspecting a lesion of the cerebellum, 
we cannot, in their absence, diagnosticate cerebellar disease 
with any degree of certainty. 

4. As vomiting is frequently an accompaniment of other 
intracranial affections, is lacking in all cases of distinctive 
lesions of the cerebellum, and is not always present in those 
due to pressure from contiguous organs, it is not of itself con- 
clusive evidence of cerebellar disease, though when constant 

* Op. cit. 



56 INTRACRANIAL DISEASES. 

and severe it may assist in the diagnosis. The same is also 
true of loss or impairment of sight, and other interocular 
symptoms. 

5. Anarthia, headache, and other, even the most diverse, 
derangements of the motor and sensory cerebral and spinal 
nerves may exist in conjunction with cerebellar disease, but 
as they are for the most part due only to pressure, they are of 
no diagnostic importance, and may even lead to errors of 
diagnosis. Occasionally, however, a symptom of this kind 
may be of some importance, as where paralysis of the whole 
of the right facial nerve points to the existence of a tumor on 
the corresponding side, and decided hemiplegia as having its 
seat on the basilar surface. 

6. The only lesions of the crus cerebelli which are of diag- 
nostic value, are those of an irritative character, and then only 
when the connection of the crus with the cerebellum is not in- 
terfered with. The symptoms referred to, consist in forced po- 
sitions of the trunk, head, and eyes, rotations about the long 
axis of the body, and vertigo, with the inclination to fall to 
one side. 

7. Of these symptoms, the turning of the body (which may 
take place in either direction) and the movement of the head 
and eyes, are the only ones which are characteristic of crus- 
cerebellar disease, and are wholly confined to lesions of the 
middle peduncle. 



LESIONS OF THE CEREBROSPINAL ISTHMUS. 57 



CHAPTER IV. 

LESIONS OF THE CEREBKO-SPINAL ISTHMUS. 

We have already stated that the most marked pathological 
distinction between diseases of the cerebrum and those of the 
spinal cord, is, that while the cord is distinguished by the ex- 
tensive existence in it of those lesions denominated systemic, 
the cerebrum is characterized by no such mode of pathologi- 
cal alteration. On the contrary, no systemic lesion is at pres- 
ent known to exist in the brain. The contrast will be still 
greater, if we take into consideration the fact pointed out by 
Charcot,* that the most common anatomical cause of disease 
in the encephalon, haemorrhage by vascular rupture, whether 
resulting from the alteration known under the name of miliary 
aneurism, from softening consecutive to arterial narrowing, or 
from thrombosis or embolism, is something which in the 
spinal cord is almost unknown. 

Now, the various regions of the isthmus, by which is meant 
the crura cerebri, the pons Varolii, and the medulla oblongata, 
constitute, so to speak, the transition between the cerebrum 
and the spinal cord; for in the former, and more particularly 
in the medulla oblongata, are found systemic lesions similar 
to those seen in the cord, and on the other hand, a considerable 
number of haemorrhages and softenings are found resulting 
from vascular lesions, more especially in the pons, the pathol- 
ogy of which approaches more nearly that of the cerebrum. 

Bastion says that some lesions of the crus cerebri can be 
diagnosed with the greatest certainty. Nothnagel, on the 
contrar3 r , asserts that it cannot be affirmed with absolute cer- 
tainty that lesions of these parts give rise to well-marked 

* Op. cit. 



58 INTRACRANIAL DISEASES. 

symptoms. The truth appears to be, however, that when the 
lesion involves only the upper and outer part of the crus, that 
is, the part next to the cerebral hemispheres, the symptoms so 
closely resemble those met with in lesions of the optic thala- 
mus, that no sufficient distinction can be made between them ; 
but if the lesion should implicate the inner and inferior part 
of the crus, that is, the part near the pons, or if there should 
be a larger lesion, involving both the pons and the contiguous 
parts of the crus, so that the motor-oculi nerve on the same 
side becomes paralyzed simultaneously with the occurrence of 
crossed hemiplegia, the diagnosis would be neither difficult nor 
uncertain. 

The symptoms produced by lesions in the lower and inner 
part of the crus cerebri, are those caused by a peculiar form of 
what is known as alternate paralysis. The motor-oculi nerve 
is paralyzed on the side of the lesion, and as a consequence, 
all the muscles of the eyeball are paralyzed, except the exter- 
nal rectus and the superior oblique, so that it is impossible to 
move the eye, except slightly in an outward and upward di- 
rection. The paralysis of this nerve also causes a partial clos- 
ure of the eye on the same side from dropping of the upper 
lid, dilatation and sluggishness of the pupil, external strabis- 
mus, and double vision. At the same time there is a hemi- 
plegic condition of the opposite side of the face and body, in 
consequence of wmich the tongue deviates towards the para- 
lyzed side; articulation becomes generally more or less im- 
paired; and sensibility on the paralyzed side is usually greatly 
diminished, especially in the limbs, the temperature of which 
is sometimes considerably elevated. 

Similar symptoms to the above are produced by a lesion in 
one lateral half of the pons Varolii, especially in the lower 
part of it, where the paralysis of the face exists on the side of 
the brain lesion, and a more or less complete motor and sensory 
paralysis of the trunk and limbs on the opposite side. A lesion 
in the upper part of one lateral half of the pons produces the 
same general effect as in the lower part, except that the facial 
paralysis exists on the same side of the body as that of the 
paralyzed limbs. In both cases the paralysis is generally well- 



LESIONS OP THE CEREBRO-SPINAL ISTHMUS. 59 

marked, involving not only the superficial muscles of the face, 
but those concerned in articulation and deglutition. Sensi- 
bility is generally impaired in proportion as the lesion ap- 
proaches or involves the side of the pons. Occasionally we 
have unilateral hyperesthesia instead of anaesthesia; and 
either condition may exist with or without painful or other 
abnormal sensations in the paralyzed limbs. If the lesion 
involve the lateral part of the pons, similar symptoms may 
also present themselves in the face, in consequence of the im- 
plication of the trigeminus, together with paresis of the muscles 
of mastication, provided the motor division is also injured. 

When the central parts of the pons are involved, if the 
lesions be extensive, the most profound apoplectic symptoms 
may appear, and if suddenly produced, death may speedily 
ensue. Under these circumstances, if life be prolonged for 
several hours or days, the temperature gradually rises on both 
sides of the body, until at the time of death it often reaches a 
maximum of 109° or 110° F. 

Less extensive lesions of the central parts of the pons may 
also cause insensibility and coma, which, however, may after- 
wards gradually disappear. We then find a condition of 
general paralysis existing, both sides of the body being pretty 
equally affected. In these cases, if there is diminished or per- 
verted insensibility, and at the same time well-marked facial 
paralysis, together with difficulty in swallowing and impaired 
articulation, the latter not aphasic, we may safely conclude 
that the symptoms are caused by a central lesion of the pons 
Varolii. 

Slight or irritative lesions of the pons, instead of producing 
apoplectic symptoms, may in the beginning give rise to epi- 
leptiform convulsions, especially if the injury occurs suddenly. 
In other cases, however, such lesions neither produce convul- 
sions nor loss of consciousness. If they irritate the fourth 
ventricle we may have diabetes mellitus, and if the lower part 
of the ventricle be implicated, as may happen if the medulla 
oblongata instead of the pons should be the seat of the in- 
jury, it may either take the form of diabetes insipidus, or of 
albuminuria. 



60 INTRACRANIAL DISEASES. 

Other symptoms also occur in lesions of the pons, such as 
early rigidity of the paralyzed limbs, trismus, or rigidity of 
some of the cervical muscles, conjugated deviation of the eyes, 
and a peculiar mental condition, known as emotional weakness, 
apparently of a hysterical character. Perhaps, as suggested 
by Althaus,* the polyuria, so frequently associated with hys- 
teria, and which, as we have just seen, may arise from irrita- 
tion of the lower part of the fourth ventricle, is a concomitant 
symptom of the same condition. 

Lesions of the medulla oblongata, in addition to the usual 
symptoms of paralysis, give rise to the phenomena due to im- 
plication of nerve-roots, such as respiratory and circulatory 
disturbances, aphonia, dysphagia, anaesthesia, dysesthesia, etc. 
Their diagnostic value, according to the estimate placed upon 
them by Nothnagel and other leading authorities, is given in 
the following summary: 

1. Lesions of the crura cerebri may produce motor, sensory, 
and vaso-motor symptoms, but the phenomena are not usually 
sufficiently distinctive to serve as diagnostic marks of disease 
of the crura cerebri, as they may also occur in lesions of the 
upper part of the pons, or of the corpus striatum. 

2. The paralysis resulting from lesions of the crura cerebri 
generally involves, not only the nerve-tracts of the extremities 
of the opposite side, but also of the facial, hypoglossal, and tri- 
geminus of the opposite side. 

3. A lesion of the crus can. only be diagnosticated with 
certainty, when a paralysis of the oculo-motor nerve of the 
same side occurs suddenly, and simultaneously with paralysis 
of the nerves of the upper and lower extremities, or the facial 
nerve of the opposite side. 

4. Motor and sensory disturbances of single nerve-tracts, 
and abnormalities in the excretion of urine, are of no diag- 
nostic value in lesions of the crus cerebri. 

5. Stationary destructive lesions of the pons Varolii derange 
the functions of the motor, sensor} T , and vaso-motor nerves of 
the extremities, and the fifth, sixth, seventh, twelfth, and pos- 
sibly the eighth and eleventh cranial nerves, the number of 

* " Diseases of the Nervous System," 1878. 



LESIONS OF THE CEREBRO-SPINAL ISTHMUS. 61 

nerves involved varying according to the extent and exact 
situation of the lesion. 

6. The same group of symptoms are often met with in 
lesions of the pons that occur in those of the cerebrum, and 
cannot be distinguished from them unless they occur in con- 
junction with difficulties of articulation, and even inability to 
speak, when they may indicate with some degree of probability 
a lesion of the pons. 

7. The only very certain indication of the existence of an 
intrapontine lesion, is the sudden onset of a well-marked form 
of cross-paralysis, which involves the motor and sensory nerves 
of the extremities on the side opposite to that of the lesion, 
and the trigeminus, abducens, facial, and hypoglossus, on the 
side corresponding to that of the lesion. 

8. So far as relates to the implication of special nerves, it 
may be said that, if the abducens be paralyzed, and the other 
symptoms indicate at the same time the existence of an intra- 
cranial lesion, the latter will almost certainly be located in the 
pons Varolii. 

9. Disturbances of respiration and of the circulation, diffi- 
culty of deglutition, and spasm of individual muscles, are only 
of importance, as aids to diagnosis in diseases of the pons, 
when accompanied by more characteristic symptoms. 

10. Lesions of the medulla oblongata frequently produce no 
other symptoms than those due to paralysis of the extremities, 
and hence cannot be diagnosticated with any degree of cer- 
tainty ; but when the paralysis is associated with aphonia, and 
with respiratory and circulatory disturbances, they may gener- 
ally be safely referred to injury of the medulla, since these 
symptoms are not observed among those of destroying lesions 
of other parts of the brain. 

11. If any one of the symptoms which may arise from im- 
plication of the nerve-roots of the medulla be wanting, it not 
only aids us in more exactly locating the seat of the lesion, 
but also helps us to distinguish the lesion from that which 
produces progressive bulbar paralysis.* 

* See Nervous Diseases, p. 168. 



G2 INTRACRANIAL DISEASES. 



PART II. 

INTRACRANIAL DISEASES. 

SECTION I. 

CEREBRAL AFFECTIONS. 



CHAPTER I. 

ANEMIA OF THE BEAIN. 

That the quantity of blood within the cranial cavity is al- 
ways the same, as was formerly taught by the Edinburgh pro- 
fessors, is no longer an open question, having been fully settled 
in the negative by recent physiological experiments, as well as 
by abundant clinical and necroscopical evidence. Even were 
the brain entirely incompressible, which is not the case, varia- 
tions in the quantity of blood circulating in it is rendered 
possible, not only by the vessels which pass between the two 
surfaces of the skull, but especially by the changes which take 
place in the quantity of the cerebro-spinal fluid, which is in an 
inverse ratio to the amount of blood contained in the cerebro- 
spinal blood-vessels. For example, in cerebral hyperemia, 
where the vessels of the brain are found loaded with blood, the 
cerebro-spinal fluid is almost entirely absent; while, on the 
other hand, it is greatly increased in hydrocephalus, where the 
brain presents an anaemic or exsanguine appearance. More- 
over, Donders, who watched the cerebral circulation through a 



AN.EMIA OF THE BRAIN. 63 

glass crystal inserted in an opening made in the skull of ani- 
mals, saw marked variations in the size of the blood-vessels of 
the pia mater, which became dilated at every expiration. 

There are three distinct forms of cerebral anaemia, namely, 
(1) hypsemia, which consists in a diminished supply of blood 
circulating in the vessels of the brain ; (2) hydremia, in which 
the circulatory fluid is deficient in haeinatin, the blood being 
too watery ; and (3) hypsemia et hydremia, in w T hich both con- 
ditions exist. The first may be referred to whatever cause im- 
pedes the flow of blood to the brain, to contraction of the cere- 
bral vessels by spasm or otherwise, or to any other condition 
whereby the intracranial space is lessened ; the second, to the 
various causes which produce impoverishment of the blood, 
and give rise to general anaemia ; and the third, to sanguine- 
ous losses, which, when excessive, always produce both paucity 
and poverty of the circulating fluid. 

Symptoms. — The symptoms vary considerably, according 
as the anaemia is gradually or suddenly produced. When it 
occurs gradually, the symptoms at first are similar to those of 
the opposite condition of hyperaemia, namely, great excitement 
of the cerebral functions, headache, flashes of light before the 
eyes, confusion of sight, humming in the ears, vertigo, loss of 
memory, and sometimes convulsions. At a later period, if the 
disease goes on. unchecked, symptoms of paralysis may super- 
vene. This is particular^ the case with infants and children, 
in whom a protracted diarrhoea is apt to produce a state of 
general and cerebral anaemia. The symptoms in these cases 
so closely resemble those of acute hydrocephalus, as to have 
had the name of " hydrocephaloid " applied to them. In ad- 
dition to the symptoms above mentioned, the stage of excite- 
ment is marked by a flushed face, hot skin, frequent pulse, 
and a contracted pupil. This stage is soon succeeded by that 
of prostration and stupor. The face is pale, the pupils are 
dilated and fixed, and the special senses are lost ; complete in- 
sensibility supervenes, the respiration becomes embarrassed, 
the pulse vanishes, and, unless the condition is quickly re- 
lieved, the case soon ends in death. 

In the aged, however, the symptoms are somewhat different. 



64 INTRACRANIAL DISEASES. 

Iii these cases there is generally a narrowing of the cerebral 
arteries, in consequence of atheromatous degeneration of the 
inner coat ; and the circulation is still further impeded by the 
rigidity of the vascular walls ; for liquids are propelled more 
easily through elastic than through inelastic tubes. Another 
impediment in these cases is cardiac weakness, which is usu- 
ally a marked symptom in advanced life. As a consequence, 
such subjects suffer greatly from vertigo, the slightest emotion 
or muscular effort being sufficient, in many cases, to bring it 
on. In fact, it is no uncommon thing for attacks of vertigo to 
appear and disappear several times a clay without any appar- 
ent cause. If standing, the patient suddenly becomes blind, 
staggers, and, if not supported, falls to the ground. The hori- 
zontal position soon restores the brain to its normal condition, 
but, owing to the debility of the heart, the least exertion again 
disturbs the circulation, and the attack is liable at any time 
to be renewed. During the stage of excitement, which is not 
wholly wanting even in the aged, the temper is more or 
less irritable, the special senses are perverted, and there is 
more or less intolerance of light and noise. This stage, which 
is generally short and variable, is followed by great depres- 
sion. The speech becomes slow, the mind apathetic, and, in 
many instances, the patient gradually sinks into a state of se- 
nile dementia. Generally the most marked symptom in these 
cases is drowsiness — a drowsiness, however, from which the 
patient may be easily aroused, but only to relapse again into 
sleep, sometimes alternating with a low delirium. As before 
stated, the muscular system is greatly enfeebled, and the heart's 
action is weak, irregular, and easily disturbed. 

When cerebral anaemia sets in suddenly, as in flooding, 
traumatic haemorrhages, and other rapid losses of blood, the 
symptoms presented are those of syncope, namely : rapid loss of 
consciousness, of the senses, and of voluntary motion, accom- 
panied with a retarded pulse and respiration, and frequently 
with slight convulsions. At first everything turns black; 
vertigo, tinnitus aurium, faintness, sickness of the stomach, 
and vomiting, rapidly supervene; the surface becomes cold 
and pale, the pulse small and scarcely perceptible, and the 



ANJEMIA OF THE BRAIN. Q5 

respiration slow and irregular ; insensibility, trembling, and 
convulsions frequently follow ; and these are succeeded in some 
cases by delirium and death. 

Acute attacks of cerebral anaemia do not, however, always 
depend upon sudden loss of blood, but may arise from shock 
or fright. This is called vaso-motor ansemia, and is of different 
degrees of intensity. When slight, it simply causes pallor, 
more particularly of the face, with perhaps some chilliness of 
the skin. Severe attacks excite such an intense spasm of the 
cerebral vessels as to entirely empty the arterioles of blood, 
inducing vertigo, fainting, insensibility, and, in some cases, 
sudden death. In most cases, however, relaxation of the cere- 
bral vessels quickly follows, and is succeeded by the opposite 
condition of hyperemia, attended by excitement, and in some 
instances by delirium — symptoms which gradually disappear 
as the cerebral circulation becomes equalized. 

Owing to the close vaso-motor connection of the blood-vessels 
of the posterior lobes with those of the abdominal viscera, 
anaemia of these lobes are sometimes accompanied with dis- 
turbances of the abdominal circulation sufficient to give rise 
to congestion of the liver, dyspepsia, constipation, disease of the 
uterus and of other abdominal organs; hence the frequent 
association of this form of anaemia with melancholy and hypo- 
chondria, which often appear to be of abdominal, rather than 
of cerebral origin. 

Instead of simple paresis, there may be actual paralysis, and 
this may be either partial or general. Several cases are on 
record where hemiplegia was caused by venesection, the 
anaemia having been mistaken for cerebral congestion. This 
mistake is especially liable to be made in the case of young 
children suffering from exhausting diarrhoea, on account of 
the similarity of the symptoms to those of tubercular menin- 
gitis, as before mentioned. 

Causes. — Of the various causes which give rise to cerebral 
anaemia, none is more common, or more potent, than the copi- 
ous and protracted bleeding frequently met with in cases of 
flooding after childbirth, or in connection with miscarriages 
and abortions, and in the various forms of uterine haemor- 
5 



GG INTRACRANIAL DISEASES. 

rhage. Excessive menstruation, also, as well as venesection, 
hemorrhoidal fluxes, and even nose-bleed, occasionally produce 
it. Injury of large blood-vessels, the rupture of aneurisms, 
and the ligature of the carotid artery, have all caused it; and 
in a few cases in which both carotids have been tied, death 
has resulted from the cerebral anaemia thus induced. 

Other debilitating discharges, such as chronic diarrhoea and 
dysentery, overlactation, long-continued suppuration, and all 
diseases which impoverish the blood, such as cancer, tubercu- 
losis, chronic nephritis, lead and mercurial poisoning, etc., are 
capable of producing it. Insufficient nutrition may likewise 
so impair the quality of the blood as to have a similar effect. 

Cerebral anaemia may also result from any impediment to 
the circulation which prevents the cerebral vessels from receiv- 
ing an adequate supply of blood, as in cases where there is 
aortic obstruction or mitral regurgitation; or in fatty degener- 
ation of the heart and myocarditis, where the organ is too 
feeble to carry sufficient blood to the brain ; also in those cases 
where the intracranial space is much encroached upon by 
tumors, extravasations of blood, or the effusion of serum. 

The sudden diversion of large quantities of blood from the 
arterial to the venous system, as in tapping for ascites, or to 
remote organs or parts, as in the applications of Jounod's cup- 
ping boot, will sometimes be followed by this condition ; at 
least syncope is not an uncommon result of such operations. 

Cerebral anaemia is sometimes induced by the injudicious 
use of certain medicines, such as arsenic, calomel, tobacco, tar- 
tar emetic, oxide of zinc, and the various bromides. Allopath- 
ists frequently take advantage of this property of the bromides 
to produce artificial sleep, especially in cases where the in- 
somnia is caused by cerebral hyperemia. The same property, 
of course, renders these remedies homoeopathic to cerebral 
anem ia. 

Anemia of the brain may be produced by certain mental 
emotions, especially fright, the shock of which is sometimes 
sufficient to cause syncope, and even death. How often people 
faint from the most trifling surgical operations, such as vacci- 
nation. I once witnessed a case of this kind in a strong, 



AN.EMIA OF THE BRAIN. 67 

robust farmer, who fainted entirely away before a particle of 
blood was drawn. 

The passage of even a weak galvanic current through the 
brain often causes cardiac depression and syncope, and may so 
paralyze the action of the heart as to prove fatal. 

Hammond* says that excessive mental exertion may pro- 
duce cerebral anaemia. We know that this is a very common 
cause of cerebral congestion, but anaemia of the brain can only 
arise from it as a secondary effect of nervous exhaustion. I 
have myself witnessed it in this class of cases, but onty in con- 
nection with general anaemia and neurasthenia. 

Diagnosis. — Great care is necessary in some cases, espe- 
cially with children, to distinguish cerebral ansemia from 
cerebral congestion. When caused by debilitating losses, and 
especially when associated with general ansemia, or with an 
impaired state of the assimilative functions, the history of the 
case, together with the fact that the symptoms of cerebal anae- 
mia diminish or disappear when the patient is in the recum- 
bent position, will generally serve to distinguish it from 
hyperaemia of the brain, with which alone it is liable to be 
confounded. In other cases it may be necessary to atten- 
tively consider all the characteristic symptoms of the disease. 
Thus, not only are the pain and vertigo increased by assum- 
ing the erect position, but the former, instead of being general, 
is usually limited to a particular part of the head; the face is 
pale, the skin cold, the pulse weak and rapid, and the pupils 
dilated; the ophthalmoscope exhibits retinal anaemia, and the 
patient, instead of being wakeful, is often overcome by drowsi- 
ness. Moreover, exertion and lowering treatment always in- 
crease, whilst the contrary influences mitigate, the disorder. 

Prognosis. — However induced, cerebral anaemia is always 
attended with great danger to life, especially in the case of 
children, though when recognized and taken in hand early 
the disease, even in its acute form, will generally yield to ap- 
propriate treatment. But when there is such a sudden and 
profuse loss of blood as to render the patient pulseless, or 

* " Diseases of the Brain," Seventh ed., 1881. 



68 INTRACRANIAL DISEASES. 

cause convulsions, recovery is always a matter of considerable 
doubt. 

Morbid Anatomy. — The veins of the pia mater are found 
on post-mortem examination to be nearly empty, and the 
small quantity of blood contained in them, and in the sinuses 
of the dura mater, is thin and watery/ The grey matter of the 
brain is so pale as to be nearly white, and the white substance 
has an abnormally white, or milky appearance, owing to the 
absence of the ordinary blood-points seen on section. The 
meshes of the pia mater contain an unusual quantity of 
serum, but the ventricles of the brain are generally empty. 

Pathology. — That the symptoms of cerebral anaemia are 
caused in most cases by an insufficient supply of blood to the 
brain, and in others by an altered or impoverished state of 
that fluid, has been proven by the independent investigations 
of many observers. Jacobi, Fleming, and Hammond, by com- 
pressing the carotid arteries, and thereby cutting off the usual 
supply of blood to the brain, produced all the characteristic 
symptoms of the disease, including convulsions. Nothnagel, 
by irritating the peripheral nerves, produced similar phe- 
nomena in animals by reflex action. Kussmaul and Tenner 
proved that, while hyperemia of the brain does not excite con- 
vulsions, faradization of the cervical sympathetic may cause 
not only dilatation of the pupil, but anaemia of the retina and 
convulsions, and that, too, notwithstanding the fact that only 
a portion of the vaso-motor nerves of the brain pass through 
the cervical sympathetic. They showed, also, that both cere- 
bral anaemia and convulsions may be produced by simply 
suppressing the breathing, and thereby depriving the blood of 
oxygen. 

We have seen that many cases of cerebral anaemia are due 
to an impoverished condition of the blood. In these cases 
there is a deficiency of the red corpuscles; and as these are 
the carriers of oxygen, the effect on the nutrition of the brain 
is the same as though the quantity of blood sent to that organ 
was below the normal standard; the only difference being, 
that the symptoms of cerebral anaemia are developed in a 
gradual instead of a sudden manner. 



ANEMIA OF THE BRAIN. ij\) 

Treatment. — In simple syncope, all that is generally re- 
quisite in the way of treatment is, to place the patient, as 
quickly as possible, in a horizontal or recumbent position, so 
as to favor a return of blood to the brain. If, however, the 
fainting is of frequent occurrence, it will be found to depend 
upon general anaemia, or some other affection, against which 
the treatment will need to be specially directed. Thus, an ex- 
hausting diarrhoea, dysentery, or other acute or chronic dis- 
charge, will not only require to be promptly arrested, but the 
quality of the blood should be improved by the use of such 
articles of diet as are best calculated to restore the lost elements, 
more particularly the various forms of animal food, such as beef- 
tea, milk, eggs, and the different kinds of meat. Even in these 
cases the recumbent position should be enjoined, especially if 
the heart's impulse is much weakened; nor should the patient 
be allowed to assume the erect position, even for the evacua- 
tion of the bladder and bowels, so long as any considerable 
liability to syncope exists. 

We have the testimony of Hammond, that a weak galvanic 
current is decidedly beneficial in these cases. This result is 
somewhat puzzling to this author, as the primary galvanic 
current applied to the brain or sympathetic nerve contracts the 
cerebral blood-vessels, instead of dilating them; just what it 
should do if it acts homoeopathicall} 7 , and hence, although he 
does not comprehend its action, he very properly advises that 
the tension should be quite low, and that the current should 
only be passed for a few seconds at a time. 

The Nitrite of Amyl is a good palliative remedy in the treat- 
ment of cerebral anaemia, especially in acute cases, but as it 
causes dilatation, instead of contraction, of the cerebral vessels, 
it will need to be used low. A few drops, inhaled from a 
handkerchief, will, as a general rule, quickly dissipate the most 
alarming attack of syncope, especially if it be the result of a 
feeble action of the heart. This remedy is to be preferred, in 
most cases, to any other form of stimulant, not only on ac- 
count of its promptness of action, but because it may be re- 
peated as often as may be necessary without any deleterious 
result. 



70 INTRACRANIAL DISEASES. 

General Indications. — 1, Calc., Carb. veg., China, Ferr., Helon., 
Hydras.; 2, Arn., Ars., Camph., Puis., Scilla, Staph., Sulph.; 3, 
Bell., Bry., Cin., Con., Graph., Ign., Lach., Lycop., Merc, Natr., 
Natr. mur., Nux v., Phos., Phos. ac, Rhus,' Sep., Sil., Verat. 

Vital Fluids. — When caused by loss of: 1, Calc., Chin., Ferr., 
Nux v.; 2, Carb. veg., Cin., Helon., Hydras., Phos. ac, Staph., 
Sulph. 

Convulsions. — Ars., Bell., Calc. c, Camph., Cina, Con., Igna., 
Lycop., Nux v., Puis., Sulph., Verat. 

Delirium. — Ars., Bell., Bry., Igna., Lach., Lycop., Phos. ac, 
Scilla, Sepia, Sulph., Verat. 

Vertigo. — Ars., Baryta c, Bell., Carb. veg., Graph., Lycop., 
Nux v., Phos. ac, Puis., Sepia, Sil., Sulph., Verat. 

Special Indications. — Arsenicum. — Great prostration, with rapid 
sinking of the vital forces; pale, chlorotic colored face; violent 
headache, noises in the ears, dimness of vision, vanishing of 
the senses, impaired memory; great anguish, restlessness and 
fear of death; vertigo, syncope, delirium, chilliness. Espe- 
cially suited to cases aggravated by the injudicious use of 
Ferrum. 

Camphor. — Violent throbbing headache ; pale, cold skin ; 
vanishing of the senses; great embarrassment of the respiration 
and circulation; spasms and convulsions. Hahnemann says of 
this remedy : " Vertigo, loss of consciousness, and coldness of 
the body, appear to be primary symptoms of a dose of Cam- 
phor, and point to a diminished afflux of the blood to those 
parts which are distant from the heart." Camphor is best 
adapted to those cases of cerebral anaemia which take the form 
of syncope, especially when caused by haemorrhage, diarrhoea, 
cholera, etc. 

China. — Cerebral anaemia, caused by the excessive loss of 
animal fluids, as in haemorrhage, spermatorrhoea, diarrhoea, 
leucorrhoea, overlactation, etc. ; headache, especially in the 
morning; ringing in the ears; obscuration of sight ; pale, cold 
face; coldness of the extremities; great debility, with tingling 
and trembling, or twitching of the muscles and limbs ; faint- 
ness, which is relieved by lying down ; vertigo, especially on 
raising the head ; insomnia. 



AN.EMIA OF THE BRAIN. 71 

Cina. — Paleness of the face, especially around the nose and 
mouth ; transient dizziness, with obscuration of sight ; faint- 
ness, relieved by lying down ; spasms and convulsions ; para- 
lytic lameness. In children, especially when complicated by 
verminous irritation. 

Ferrum. — Hydrsemia, with great paleness of the face, lips, 
and mucous membrane of the mouth ; noises in the head ; 
bellows-sound of the heart ; muscles flabby and weak ; easily 
exhausted from slight exertion ; oedema of the face and limbs ; 
hammering headache; shortness of breath. This remedy is 
more particularly adapted to chlorotic females, and to cases 
resulting from passive haemorrhages. 

Ipecacuanha. — Pale face, with blue margins around the e} T es; 
cold hands and feet ; nausea, with or without vomiting ; vio- 
lent headache, excited and aggravated by stooping ; vertigo, 
with temporary loss of consciousness ; convulsive movements 
of the limbs ; heaviness of the head, with great drowsiness ; 
restlessness and sleeplessness at night. This remedy is best 
adapted to children, and to cases resulting from the loss of ani- 
mal fluids. 

Katrum mur. — Pale, sallow complexion; great depression of 
spirits ; circulation excited by every movement of the body ; 
pressure and swelling of the stomach ; excessive weakness and 
prostration ; hard, irregular and insufficient stools ; great 
drowsiness, especially during the daytime. Cerebral anaemia, 
resulting from the loss of animal fluids, or from onanism. 

Natrum sulph. — Great drowsiness, languor and prostration ; 
watery condition of the blood ; constant chilliness, especially 
in the evening ; trembling of the body, with jerking in the 
limbs. More particularly adapted to what is called the hydro- 
genoid constitution. 

JSfux vom. — Nausea and vomiting, with frequent eructations 
of sour-smelling fluids or food; anorexia, with loathing of 
food ; anaemia, with coldness of the whole body ; drowsiness, 
vertigo, mental weakness, constipation, syncope, sleeplessness 
at night, spasms and convulsions. Especially suited to cases 
complicated with gastric irritation, indigestion, and consti- 
pation. 



72 INTRACRANIAL DISEASES. 

Secale cor. — Cerebral ansomia, complicated with diarrhoea, 
metrorrhagia, spasms, and convulsions. 

Sulphur. — Chronic cases, occurring in scrofulous, or cold, 
phlegmatic constitutions, especially when other indicated reme- 
dies fail to produce any lasting benefit ; also, when preceded 
or accompanied by eruptions, or when caused by their sup- 
pression. 

Veratrum alb. — Acute cases caused by violent purging, 
attended with fainting fits, spasms, and convulsions, and fol- 
lowed or accompanied by paralytic weakness. This remedy is 
suited to conditions similar to those for which Secale is indi- 
cated, but with this difference, that while the latter is better 
adapted to cases arising from flooding, Veratrum is better 
suited to such cases as depend on losses occasioned by exces- 
sive alvine discharges. 



CEREBRAL HYPEREMIA. 73 



CHAPTER II. 

CEREBRAL HYPEREMIA. 

Cerebral hyperemia, or congestion of the brain, is of two 
kinds, active or arterial, and passive or venous. In the former, 
a larger quantity of blood than usual is sent to the brain, 
constituting what is termed rush of blood to the head. In the 
latter, there is no actual increase in the amount of blood sent 
to the brain, but, owing to obstruction, it does not return freely 
through the cerebral veins, which therefore become over- 
charged w T ith blood, constituting what is sometimes called stag- 
nation of blood in the brain, or hyperemia by stasis. 

Symptoms. — There are two distinct classes of symptoms 
met with in this disease, namely, those of excitation and those 
of depression. The former embraces such symptoms as wake- 
fulness, or morbid vigilance ; pain in the head ; intolerance of 
light, noise and pressure ; singing or ringing in the ears ; 
sparks or dark specks before the eyes ; contraction of the pu- 
pils ; redness and heat of the face ; full and strong pulse ; 
throbbing of the carotids ; grating of the teeth ; restlessness at 
night ; vivid dreams ; jerking of the limbs ; vertigo ; convul- 
sions. The symptoms of depression are for the most part the 
reverse of these. Thus, the head feels dull and heavy; the 
limbs go to sleep, and have a heavy, paralytic feeling; there is 
great dulness of the senses; the pupils are dilated, the pulse 
small and frequent, and the respiration slow, irregular, or ster- 
torous; nausea, vomiting, and constipation are of frequent 
occurrence, and there is generally more or less anaesthesia and 
paralysis. 

The symptoms, however, vary greatly in different cases, 
both as to number and intensity. In some instances, the only 



74 INTRACRANIAL DISEASES. 

symptom complained of is sleeplessness. This condition is per- 
haps the most constant of any, as sound sleep is impossible 
while the brain is in a state of active hyperemia, and conse- 
quently in an excited condition. Hence, although the patient 
may be greatly exhausted, and may even have lost much sleep, 
it is generally not until after midnight, and frequently not 
until near morning, that the cerebral circulation becomes suffi- 
ciently tranquil for the brain to sleep, and when it does, it is 
apt to be more or less disturbed by unpleasant dreams, so that 
when the patient awakes, he generally feels as tired and unre- 
freshed by it as though slumber had never visited his eyelids. 

But it is not often that the only evidence of cerebral hyper- 
emia is wakefulness. In most cases some other of the symptoms 
of excitability are superadded. Headache, especially, is almost 
always present, and sometimes it constitutes the most striking 
feature of the disease. When severe, the suffering may be so 
great as to unfit the patient for every kind of mental or physi- 
cal labor ; but in most cases it consists of a dull, aching pain, 
such as we w r ould expect from overdistension of an organ in- 
closed, as is the brain, within rigid walls. Even when no 
actual pain exists, there is always present a more or less un- 
comfortable feeling in the head, generally a sensation of ful- 
ness or tightness, which changes to pain whenever the 
patient's head assumes a dependent position, or when he en- 
gages in any protracted mental or physical employment. 

Next in frequency, generally, are derangements of the special 
senses. Various noises in the ears, such as singing, ringing of 
bells, and the different forms of tinnitus aurium, are experienced 
in these cases, and sometimes the sound, which is wholly sub- 
jective, appears to come from the occipital region. Occasion- 
ally, the sound appears to be of the nature of an explosion, 
like the report of a pistol, which so startles and deceives the 
patient that he sometimes imagines himself to be the object of 
a murderous assault. In other cases the sensation is that of 
something suddenly giving way within the head, and is usu- 
ally accompanied with a sharp, snapping sound. These cases 
are generally preceded or accompanied by intense vertigo and 
pain in the head, followed in some instances by unconscious- 



CEREBRAL HYPEREMIA. 75 

ness, and appear to belong to what Dr. Searle styles " a new 
form of nervous disease." 

Owing to a hypersesthetic condition of the auditory nerve, 
the sense of hearing is often morbidly acute, so that sounds 
that would not attract the attention of others, not only annoy, 
but frequently become intolerable to the patient. Even the 
ticking of a clock, or the barking of a dog, may, in the excited 
condition of the patient's brain, render him almost frantic. 
This is especially apt to be the case at night, when the still- 
ness of the hour, the wakefulness of the patient, and the de- 
pendent position of the head, combine both to exalt and to 
pervert the already exaggerated sense of hearing, thus giving 
rise to a great variety of illusions and hallucinations, which 
the mental condition is ill fitted to bear or to correct. 

Of the other senses, none is more frequently disturbed than 
that of vision. The hypersemia of the retina and optic nerve, 
which are readily distinguishable by the ophthalmoscope, 
generally gives rise to more or less photophobia and lachry- 
mation, together with a variety of subjective symptoms, such 
as flashes of light, muscse volitantes, moving vapors, etc. 
These symptoms, like all others pertaining to the head, are 
aggravated by the general congestion of the cerebrum, as well 
as by any cause which increases it, such as mental and physi- 
cal exertion, dependent positions, etc. 

Hallucinations of sight are also common, but, owing to their 
frequent dependence on diseases of the eye, they are more apt 
to be referred to disturbances in that organ than to congestion 
of the brain, which is not infrequently the true cause. Even 
diplopia does not always arise from strabismus, astigmatism, 
or other form of ocular disease, being sometimes due to simple 
hypersemia of the brain; but in these cases it is generally 
transient, and limited to bright objects. 

It is no uncommon thing for the senses of smell and taste to be 
exaggerated or perverted, and even lost. I have a patient 
now under treatment who has a natural dislike of the odor 
of musk, and whose life has long been rendered miserable 
by the constant perception she has of that "intolerable 
smell." At first I was inclined to attribute the defect to the 



76 INTRACRANIAL DISEASES. 

congested state of the Schneiderian membrane, but on careful 
investigation I found that the origin of the trouble corre- 
sponded with the setting in of unequivocal signs of cerebral 
hyperemia, and, although decidedly chronic, it has already 
been considerably benefited by treatment based upon this 
view of its pathology. 

General sensibility and the poicer of motion usually suffer to a 
greater or less extent, anaesthesia of the skin being generally 
associated with muscular paresis, and cutaneous hyperesthesia 
with involuntary muscular movements of the limbs or of in- 
dividual muscles. Thus, the patient sometimes experiences 
crawling sensations about the face, scalp, and limbs, as though 
covered with live ants, while the limbs themselves feel heavy, 
cold, or numb; or the reverse state may occur, attended with 
neuralgic pains, partial convulsions, etc. 

But the most important phenomena known to arise from 
cerebral hyperemia are those pertaining to the general circula- 
tion. Dr. Hammond,* but more particularly M. Krishaber,f 
has drawn attention to a class of cases in which the heart and 
general circulation are especially involved. These cases are 
characterized by an extreme "irritability of the vascular sys- 
tem, so that the least movement, such as rising erect from the 
sitting posture, or to the sitting from the recumbent, leads to 
the acceleration of the pulse of from 20 to 30 or even 40 beats 
a minute. Besides this, there are frequent and violent palpi- 
tations, either spontaneous, or provoked by the most insignifi- 
cant causes, either mental or physical.'' 

As this presents a perfect picture of some cases of narcotine 
poisoning, and also of the cardiac disturbances sometimes 
caused by dyspeptic troubles, it will be well to consider in this 
connection the results of Krishaber's more recent investiga- 
tions on this subject. The following is a summary of the lead- 
ing symptoms, as given by Hammond :J 

The disease is sometimes developed with great suddenness, 
but ordinarily it advances little by little to completeness. 

* Op. cit. 

t "De la Neuropatliie Cerebro-cardiaque," Paris, 1873. 

t Op. cit. 



CEREBRAL HYPEREMIA. 77 

When the former is the case, the patient experiences, under 
the influence of great mental excitement, pain in the head, 
vertigo, an inability to speak, or, at least, imperfection of ar- 
ticulation. There are noises in the ears, flashes of light before 
the eyes, and occasionally, for a short time, double vision. The 
heart beats with increased force and rapidity, and is more or 
less irregular in its action; the face is flushed, and a feeling of 
suffocation is experienced. If he attempts to walk, his gait is 
uncertain or staggering, not only in consequence of the ver- 
tigo present, but from actual loss of power in the limbs. 
Numbness is commonly felt in some part of the bod}^, and 
clonic spasms of the muscles, notably of those of the face, are 
generally present. With all these physical symptoms, there 
are others indicting mental disturbance. Chief among these 
are hallucinations or illusions of the senses, particularly of 
sight and hearing. Insomnia is an almost invariable attend- 
ant, and what little sleep the patient obtains is interrupted 
by unpleasant or even frightful dreams. Gradually the dis- 
order becomes established, and the other functions, especially 
those connected with digestion, are deranged. From the first 
the urine is loaded with urates and phosphates. 

No one can mistake this assemblage of symptoms for those 
of any other disease, as it exhibits a fair representation of 
cerebral hyperemia. Such cases, however, are not always 
sudden in their onset; at least, I have known the phenomena 
to recur at regular intervals for long periods of time, the 
attacks assuming in some instances a regular tertian or quar- 
tan form, suggestive of malarial influence. Two years ago I 
had a case of this kind under treatment The subject, a man 
set. about 45 years, enjoyed good health up to about the age of 
40, when he had an attack of typhoid fever. Since that period 
he suffered from regular tertian attacks of cerebral hyperemia 
of the character above described. On his "well days," as he 
called them, his head was easy, his mind clear, the heart's 
action regular and normal, the digestive powers good, and the 
patient could walk about freely, and even attend to business. 
But on the alternate, or " sick days," he was obliged to remain 
quiet in bed, abstain from eating, and even from conversation, 



78 INTRACRANIAL DISEASES. 

as any attempt to assume the erect position, any emotional 
excitement, or even a light meal, would at once disturb the 
action of the heart, excite vertigo, noises in the ears, and all 
the other symptoms of cerebral hyperemia. He had been 
treated by several eminent physicians of the old school, most 
of whom, regarding the disease as one of malarial origin, pre- 
scribed quinine in large doses, and thus greatly aggravated his 
disorder. Others, regarding it as a case of cerebral anaemia, 
also gave tonics with a like result. To cap the climax, others 
treated him for heart disease and dyspepsia, ringing the 
changes again upon tonics and stimulants, until the poor man 
well nigh despaired of recovery. The consequence was, that 
although I at once recognized the case as one of cerebral hy- 
peremia, and treated it accordingly, it required more than 
eighteen months' appropriate treatment to effect a cure. 

Various other types of cerebral hyperemia are met with in 
practice, some of which belong to the active, and some to the 
passive form. They are known as the delirious or maniacal, 
the convulsive or epileptiform, and the apoplectic. Other minor 
types are also occasionally seen, such as the soporific, the 
paralytic, and the aphasic. 

1. The Delirious Form. — This form is generally the result 
of a high degree of active hyperemia. There is vertigo, 
throbbing in the head, flushing and heat of the face, suffusion 
of the eyes, excessive restlessness and mobility, often combined 
with weakness, or an inability to maintain the erect position, 
and delirium, generally of an active, but sometimes of a low, 
typhoid, or passive character. In some cases the patient is 
irritable, extremely nervous and peevish, and apparently labor- 
ing under an attack of hysteria, or of delirium tremens. The 
delirium is often characterized by an inclination to laugh or 
cry, to talk foolishly, to escape from some loathsome or fright- 
ful object, while the whole expression is one of terror and 
feverish excitement. In other cases the patient is attacked 
with paroxysms of acute mania, during which he is disposed 
to injure himself or others, to fight, tear off his clothing, or 
destroy the objects within his reach. In either case, after a 
variable period of excitement, the patient becomes exhausted 



CEREBRAL HYPEREMIA. 79 

and falls into a heavy stupor, accompanied by relaxation of 
the limbs, and, in some cases, by involuntary evacuations from 
the bladder and bowels. On awaking, there is more or less 
prostration, heaviness or numbness of the limbs, weakness and 
confusion of the mind, and an imbecile expression of the coun- 
tenance, from which the patient only slowly recovers. Some- 
times the injury is still more profound, paralysis being super- 
added to the above phenomena. 

2. The Convulsive Form. — The spasmodic phenomena which 
characterize this form of cerebral hyperemia resemble those 
of an ordinary epileptic seizure, being attended with a loss 
of consciousness, but without any premonitory cry or aura. 
Neither do the convulsions of cerebral hyperemia ever occur 
during sleep, since, as we have seen, true sleep is incompatible 
with a hyperaemic condition of the brain. Those convulsions 
which do occur during sleep are, so to speak, ansemic convul- 
sions, as, indeed, are probably all convulsions arising from 
irritation of the brain, whether the latter be in a state of 
general hyperemia or anaemia. In the former case the hyper- 
emia, if active, may be so severe as to lead to oedema; this 
will necessarily produce more or less anaemia of certain parts 
of the brain, which in turn may give rise to convulsions. On 
the other hand, passive or venous congestion of the brain can 
only occur by depriving that organ of its usual amount of 
arterial blood, thus causing an arterial anaemia, which may 
also excite convulsions. So that, although convulsions depend 
upon an anaemic condition of the convulsive centre in the 
brain, it is possible for them to take place, not only during a 
state of general cerebral hyperemia, but even in consequence 
of it. 

3. The Apoplectic Form. — This form is the result of the 
highest degree of cerebral hyperemia. In most cases the 
attack is preceded by the usual promonitory symptoms of apo- 
plexy, such as headache, dizziness, weight or fulness in the 
head, drowsiness, confusion of mind, hyperesthesia of the 
special senses, flushings of the face, epistaxis, and other symp- 
toms of cerebral hyperemia. Suddenly there is an increased 
determination of blood to the head, and the patient falls to 



80 INTRACRANIAL DISEASES. 

the ground in a state of insensibility. This condition, which 
is accompanied with more or less anaesthesia and paralysis, 
may last only for a few minutes, or it may continue for several 
hours. The paralysis is never complete, though it may affect 
one or all of the limbs. The muscles of the face are rarely im- 
plicated, though the patient, when spoken to loudly, answers 
in a slow, indistinct, and difficult manner. The respiration 
and circulation are more or less embarrassed, but there is 
seldom any stertor, flapping of the cheeks, or profound impli- 
cation of the respiratory centre. The pulse may be slow and 
intermittent, or quick and scarcely perceptible. There is 
generally more or less difficulty of swallowing; and although 
the patient may be temporally roused by shouting to him, the 
perception of things in general is lost. Reflex excitability, 
however, usually persists, and may even be increased. Thus, a 
loud noise or a bright light will generally attract the patient's 
attention, and will sometimes cause discomfort. In most cases 
the attack gradually passes off, leaving both mind and body 
more or less enfeebled, but without any decided loss of either 
sensation or motion. Occasionally, it is true, a certain degree 
of paresis, or even hemiplegia, may remain for a few days, but 
it disappears much more quickly than in true apoplexy. Some- 
times, however, the termination of the attack is much less 
favorable; the symptoms gradually grow worse and worse, in- 
voluntary discharges take place from the bladder and bowels, 
the patient sinks into a state of profound coma, and eventually 
dies. 

Causes. — The causes of cerebral hyperemia are very numer- 
ous. It is evident that whatever is capable of increasing the 
force of the general circulation, of augmenting the amount of 
arterial blood in the brain, or of giving it a peculiar direction 
to that organ ; and also whatever obstructs or impedes the re- 
turn of blood from the head, thus producing congestion of its 
sinuses and veins, may all act as the immediate causes of cere- 
bral hyperemia. No doubt such cases alone, without any 
peculiar predisposition, may produce the disease in most in- 
stances, but with many there is a marked liability to determi- 
nation of blood to the brain — a liability which appears to be 



CEREBRAL HYPEREMIA. 81 

hereditary ; at least it seems to run in certain families, espe- 
cially those of a sanguinous temperament. Overrichness of the 
blood, or a plethoric condition of the system, the cessation of 
growth, and the change of life, are all predisposing causes ; 
and hence the aged and those in middle life are more subject 
to it than the young, and men more than women. Hence, 
also, it is often found to be associated with free living. But 
the most powerful predisposing causes, doubtless, are diseases 
of the heart, especially pericarditis, endocarditis, and hyper- 
trophy of the left ventricle, in active hyperaemia; and dilatation 
of the right ventricle, fatty degeneration, and valvular diseases, 
in passive hyperemia. 

Among the more common exciting causes are : exposure to 
extremes of heat and cold, and especially to the direct rays of 
the sun; violent emotions; excessive mental labor; excite- 
ment of the passions, particularly the sexual ; excesses in eat- 
ing and drinking; the sudden suppression of habitual dis- 
charges, especially the haemorrhagic, such as the catamenia, 
piles, etc.; sudden and violent physicial exertion, more espe- 
cially when the head is in a dependent position, as in stooping ; 
the use of certain drugs, such as quinine, belladonna, opium, 
glonoin, nitrite of amyl, etc., and inflammatory conditions in 
the vicinity of the brain, such as quinsy, mumps, facial ery- 
sipelas, etc. 

Passive or venous hyperemia may be brought about by such 
causes as prevent a sufficiently rapid emptying of the jugular 
veins, such as a goitre or other tumor pressing upon them, or 
upon the descending vena cava; violent and prolonged strain- 
ing, as in childbirth or at stool ; playing upon wind instru- 
ments; violent fits of coughing, as in croup, whooping-cough, 
etc. ; dilatation of the right ventricle, producing tricuspid in- 
sufficiency and pulmonary congestion ; pleuritic effusions ; 
emphysema; working in compressed air; intracranial tumors; 
and cerebral embolism, thrombosis, and extravasations. 

Diagnosis. — There are some points of resemblance between 

cerebral hyperemia and intracranial haemorrhage, embolism, 

thrombosis^ vertigo, epilepsy, softening, and uraemia ; but as 

all of these affections are characterized by well-marked differ- 

6 



82 INTRACRANIAL DISEASES. 

ences, they are not liable to be mistaken for this disease, pro- 
vided proper attention is paid to the symptoms. The case is 
different, however, as regards cerebral anaemia, the first stage 
of which closely resembles that of cerebral hyperemia. Thus, 
headache, vertigo, numbness, sense of constriction, tinnitus 
aurium, dulness and confusion of mind, lassitude, impaired 
memory, and even loss of consciousness, are common to both 
diseases. But in cerebral anaemia the face, instead of being 
flushed, is pale and cold; the pupils are dilated, not con- 
tracted; there is drowsiness instead of wakefulness; the vertigo 
is increased by the erect, and diminished by the recumbent 
posit on ; the pulse, instead of being strong and slow, is weak, 
frequent, and irregular ; there is no throbbing of the carotid 
and temporal arteries, but bellows-murmurs are heard at the 
base of the heart and in the veins of the neck. Moreover, the 
opthalmoscope shows anaemia of the retina, instead of the large 
and tortuous arteries and checked disk belonging to cerebral 
hypersemia. 

Prognosis.— The prognosis in cerebral hypersemia depends 
greatly upon the form and stage of the disease. Active cere- 
bral hypersemia is a much more rapid, but less fatal form, 
than the passive. Recovery from it generally takes place 
under homoeopathic treatment, especially if it has not passed 
beyond the first stage. The passive form, though generally a 
more serious, is not a very fatal affection ; but complete re- 
coverjr from it cannot be expected -to take place unless the 
causes which produce it are removable. Pulmonary conges- 
tion appears to be one of the most frequent complications in 
fatal cases, since, according to Althaus, six out of nine cases of 
sudden death from cerebral hypersemia exhibited congestion 
of the lungs. The subjects of this disease are also liable to a 
number of other secondary lesions, such as encephalitis, soften- 
ing of the brain, cerebral haemorrhage, and general paralysis ; 
lesions especially apt to occur in the convulsive form. As 
might be expected, the danger in these cases is generally in 
proportion to the frequency of the attacks. Old school authors 
give a mortality for this disease varying from ten to twenty 
per cent. T find upon looking over my Case-Books for the 



CEREBRAL HYPEREMIA. 83 

past twenty years, during which time I have treated all such 
cases homceopathically, that of one hundred and forty-two 
well-developed cases, all but four, or at most five, recovered. 
Of the fatal cases, two (one a painter and the other a printer) 
died of softening of the brain ; one (an excessive smoker) from 
paralysis of the heart; and one (a confirmed drunkard) from 
general paralysis. Besides these, there is one case, marked 
doubtful, of a lady about forty-five years of age, who was sud- 
denly seized with delirium, and died comatose within thirty 
hours of the beginning of the attack. The diagnosis was acute 
congestion with effusion, but no post-mortem examination 
was allowed. 

Morbid Anatomy. — Although the post-mortem lesions in 
this disease are sufficiently characteristic, they are not always 
present after death — a circumstance which some have endeav- 
ored to explain by assuming that, where the hyperemia was 
of an active character, the distended arteries have emptied 
themselves just before death, either by discharging their con- 
tents into the veins, or by effusion of serum through the coats 
of the capillary vessels. 

In the great majority of cases, however, we find after death 
the cerebral vessels loaded with blood, the convolutions of the 
brain more or less obliterated, and the pia mater detached so 
as to be easily lifted from the cerebral surface. The blood- 
vessels, both of the pia mater and the substance of the brain, 
are increased in size; the latter exhibiting, on section, larger 
and more numerous blood-points than usual, and the former 
having a red or rose-colored appearance. The white matter, 
besides being increased in density and consistence, has a slight 
pinkish appearance, and the grey matter appears dark red, or 
of a violet hue. The ventricles and subarachnoid spaces are 
often filled with serum, and the veins of the pia mater are 
more or less enlarged and tortuous. 

Repeated and long-continued attacks of cerebral hyperaemia 
exhibit, on microscopical examination after death, minute 
granules of haematin in contact with the blood-vessels, and 
also, in the case of the smaller capillaries minute aneurismal 



84 INTRACRANIAL DISEASES. 

swellings. Two French observers, Durand-Fardel* and Cal- 
meil.f were the first to point out a cribriform appearance (Vetat 
crible) which is seen on making a transverse section of the 
hemispheres in these cases. This appearance, which is sup- 
posed to be due to the distension and subsequent shrinkage of 
the capillary vessels, is caused b} 7 the presence of numerous 
fine holes, which are plainly visible to the naked eye. In 
some cases the cerebral capillaries are ruptured, blood being 
extravasated into the medullary substance, and forming rose- 
colored patches; more commonly, however, the vascular dis- 
tension is relieved by effusion of serum through the coats of 
the capillaries into the brain and subarachnoid spaces. Sub- 
sequently the brain becomes atrophied, and its ventricles filled 
with serum. 

Pathology. — We have already pointed out the fact, under 
the head of cerebral anaemia (q. v.), not only that a free vas- 
cular connection exists between the outer and inner surfaces 
of the skull, but that variations in the quantity of blood within 
the cranium may easily take place by means of the equalizing 
effect of the cerebro-spinal fluid, the quantity of which appears 
to be regulated by the amount of blood present in the cerebro- 
spinal blood-vessels. Moreover, these vessels, according to 
Robin* and His,§ are surrounded throughout their entire 
length by perivascular canals, or ring-like spaces, which in 
cases of chronic hypersemia become permanently enlarged. 
Finally, by observations made through a watch crystal fixed 
in the hole of an animal's skull, the cerebral vessels themselves 
have been seen to increase and diminish in diameter accord- 
ing to the amount of pressure exerted upon their contents 
during the act of respiration. 

That such changes may take place without causing undue 
pressure upon the cerebral tissue, is shown by the experiments 
of Pagenstecher on dogs, w T ho found that about twenty-three 
fluid ounces could be injected into the cavity of the cranium 

* Traite pratique des Maladies des vieillards, deuxieme ed., Paris, 1873. 

f Be la paralysie considerie chez les alienes, etc., Paris, 1826. 

X Jour, de la Phys. de I' Horn, et des Anim., 1859. 

I Zeitseh.f. Wisnenchaft. ZooL, 1865. 



CEREBRAL HYPEREMIA. 85 

before producing symptoms of compression. It is believed, 
therefore, that in many cases of active cerebral hyperemia the 
quality of the blood favors the congestion, by giving rise to 
an undue activity of the serous membranes surrounding the 
brain, and thus exerting more or less of a suction action in 
their direction. 

Treatment. — Nearly every case of cerebral hyperemia will 
be benefited, and many will be cured, by the removal of the 
cause. Hence, the first thing to be done is, to remove or lessen, 
as far as possible, the exciting causes. Thus, the passive form 
requires rest, both physical and mental, and the avoidance of 
everything calculated to disturb the circulation or affect the 
mind, such as excesses in eating and drinking, the excitement; 
of the animal passions, and every form of mental and bodily ex- 
ertion. Active cerebral hyperemia generally requires similar 
restrictions, except that the injunction as to rest need not, in the 
majority of cases, be insisted upon to so great an extent. The 
patient, however, should abstain from all severe muscular ex- 
ertions, especially while in a stooping posture. Care should 
also be taken to keep the feet warm, the head elevated and 
cool, and the clothing about the neck and chest loose and com- 
fortable. 

Cold to the head is an important adjuvant in the treatment; 
of the active form of cerebral hyperemia. Even ice and ice- 
water may be safely and advantageously applied to the head 
and neck in these cases, provided the feet and legs are im- 
mersed in hot water at the same time. If this precaution be 
not observed, it will be safer to apply warm water to the head, 
the evaporation from which produces a comfortable sense of 
coolness, and rapidly reduces the temperature of the parts to 
which it is applied. 

Various agents are known to possess the power of contract- 
ing the cerebral blood-vessels, the most efficient of which are, 
the constant galvanic current, ergot, and the bromides of po- 
tassium, sodium, and calcium. 

The galvanic current should be applied by placing one pole 
of the battery over the sympathetic nerve in the neck, and the 
other opposite the seventh cervical vertebra ; using not to ex- 



86 INTRACRANIAL DISEASES. 

ceed ten Smee's cells, nor allowing the current to act for more 
than two or three minutes. 

Ergot and the bromides are allopathic remedies, and there- 
fore require to be used in material doses. Hammond recom- 
mends the former in drachm doses of the fluid extract, and the 
latter in twenty-grain doses, in solution, three times a day. I 
have myself obtained excellent results, in several cases, by giv- 
ing the bromides in tw T o-grain doses, every hour, but have sel- 
dom had occasion to resort to them in active cerebral hyper- 
emia, the homceopathically indicated remedies having gener- 
ally given speedy and permanent relief. 

General Indications. — When caused by mental emotions : Aeon., 
Cham., Coff., Igna., Nux v., Opi., Ver. v. 

Brain-fag: Arn., Aur., Calc. carb. and hypophos., Erythrox. c, 
Igna., Nux v., Pic. ac, Phos., Phos. ac, Puis., Rhus t., Sec. c, 
Sulph., Zinc, phosphide. 

Alcoholic drinks: Arsen., Calc. c, Gels., Ip., Lach., Nux. v., 
Puis., Opi., Ver. v., Sulph. 

Dentition : Aeon., Bell., Calc. c, Cham., CofF., Gels., Ver. v. 

Straining or injury : Aeon., Arn., Bry., Calc. c, Cic, Merc, 
Rhus t. 

Amenorrhcea: Aeon., Apis, Apoc, Bell., Bry., Calc. c, Carb. 
v., Chin., Cimicif., Coca, Cycl., Cupr., Dig., Graph., Kali c, 
Lycop., Merc, Nat. m., Phos., Puis., Rhus, t, Senec. g., Sep., 
Sulph., Xanth. 

Hemorrhoidal suppression: Aeon., Cham., Calc. c, Carb. v., 
Nux v., Puis., Sulph. 

Constipation: Bry., Igna., Nux. v., Opi., Merc, Puis., Sulph. 

Visceral congestion, or chill: Aeon., Arn., Ars., Bell., Bry., 
Calc. c, Cham., Dig., Ipec, Lycop., Merc, Rhus t., Stram., 
Sulph., Ver. 

Hypertrophy of left ventricle: Aeon., Aur., Cact. gr., Glon., 
Iod., Kalm., Spig., Spong. 

Tricuspid regurgitation: Bell., Hysoc, Kali c, Puis., Tart, 
emet. 

Vertigo, When there is much : Aeon., Arn., Bell., Calc, 
Causi, Cic, Coca, Lach., Lycop., Nit. ac, Nux v., Phos., Puis., 
Rhus t , Sep., Stram., Sil., Sulph., Ver. 



CEREBRAL HYPEREMIA. 87 

Loss of consciousness, When there is: Arm, Bell., Baryt., 
Camph., Cic.j Cupr., Hyos., Kal., Nux v., Opi., Phos. ac, Plat., 
Puis., Rhus, Stram., Ver. 

Special Indications. — Aconite. — Great restlessness and anxiety, 
with dry, burning skin; throbbing pains in the head, with 
fulness and heaviness; piercing pains in the forehead and 
temples; vertigo, especially when stooping; flashes of light 
before the eyes; photophobia; buzzing in the ears; temporary 
blindness; disposition to faint; palpitations of the heart; ag- 
gravated by movement; more or less relief in the open air. 
Especially indicated in the active form, or when caused by 
violent emotions, such as anger or fright. 

Amyl nitr. — Throbbing, with sense of heat and fulness, in 
the head; buzzing and throbbing in the ears; protrusion of 
the eyes ; flushing of the face ; beating of the carotids ; violent 
palpitations. 

Arnica. — Heat and burning in the head, with coldness of 
the remainder of the body; throbbing in the forehead and 
temples, increased by stooping or exercise; burning, buzzing 
and beating in the ears; vertigo, attended with nausea or 
vomiting; delirium, obscuration of sight, or loss of conscious- 
ness. This remedy is more particularly indicated after a blow 
or fall, or when the congestion is the result of mechanical 
violence. 

Auriun. — Heat and roaring in the head, with scintillations 
before the eyes ; desire for death, with suicidal tendency; ag- 
gravated by mental exertion. 

Belladonna. — Redness of the face and eyes; roaring and 
humming in the ears; great sensitiveness to light and noise; 
painful stitches in the head; delirium, spasms and convul- 
sions; morbid vigilance, or its opposite, stupidity; contraction 
or dilatation of the pupils ; double vision ; loss of conscious- 
ness; stiffness of the tongue and neck; aggravation of the 
symptoms by stooping, exercise, light or noise. 

Bryonia. — Painful outward pressure in the forehead and 
temples; bleeding of the nose; intolerance of light and noise; 
buzzing in the ears; startings in sleep, with twitchings of 



88 INTRACRANIAL DISEASES. 

the facial muscles; red, bloated face; great impatience and 
irritability; nausea and vomiting; constipation. 

Cactus. — Throbbing pain in the head, with red and bloated 
face; heavy, pulsating pain in the top and right side of the 
head, ameliorated by pressure, but aggravated by light and 
noise; vertigo; anxiety. 

Cimicifuga. — Severe pain in the head, especially over the 
right eye; heat and fulness of the head, with throbbing and 
pressure; pain in the temple and vertex, with a sensation as 
though it would burst; heaviness and dulness of the head; 
the brain feels too large for the skull. 

Coffea. — Great nervousness, wakefulness, and exaltation of 
the senses; heat in the head and face; epistaxis; buzzing in 
the ears ; flushing of the face, with cold feet ; red and glisten- 
ing eyes ; symptoms aggravated by talking. Well adapted to 
infantile cases, especially when caused by teething or diarrhoea. 

Gelsemium. — Dull, pressive, and stupefying headache, ex- 
tending from the occiput to the os frontis ; vertigo, with dim- 
ness of vision ; diplopia ; buzzing in the ears ; morbid vigi- 
lance, or its opposite, drowsiness; mirthfulness, alternating 
with depression of spirits ; mental confusion ; pain in the nape 
of the neck, with disposition to throw the head backward. 
This is generally one of our most reliable remedies in cerebral 
hypersemia, whether caused by teething, mental emotions, sup- 
pression of the menses, or exposure to the rays of the sun. 

Glonoin. — Determination of blood to the head ; throbbing 
headache, with very rapid pulse ; flashes of light before the 
eyes ; singing and buzzing in the ears ; fulness in the forehead 
and vertex, with dulness of mind ; fainting, with black spots 
before the eyes; vertigo; strong beating of the carotid and 
temporal arteries; great restlessness and impatience; when 
caused by extremes of heat or cold. 

Hyoscyamus. — Dark red face, with sparkling eyes ; delirious, 
drowsy, or unconscious ; great nervousness, with twitching of 
the tendons ; grating of the teeth ; sudden startings during 
sleep ; throbbing of the carotids ; double vision ; jerking of the 
limbs. 

Mercurius. — Feeling of great fulness and pressure in the 



CEREBRAL HYPEREMIA. 89 

head ; sensation as if the brain was rigidly compressed ; great 
restlessness and anguish, especially at night ; burning of the 
eyes, with lachrymation ; buzzing in the ears, with dulness of 
hearing ; headache of a tearing, boring character ; vertigo ; fre- 
quent sweating without relief. 

Nux vom. — Headache, with or without nausea or vomiting ; 
dulness and confusion of the head; drowsiness, with a tendency 
to coma, or the opposite condition of wakefulness, with burn- 
ing of the eyes, and intolerance of light and noise ; ringing in 
the ears; vertiginous intoxication and cloudiness; symptoms 
aggravated by eating, by exercise in the open air, and by coffee. 
This remedy is particularly adapted to cases caused by exces- 
sive mental labor, by the habitual use of intoxicating liquors, 
and by sedentary modes of life. 

Opium. — Comatose sleep, with apoplectic symptoms, such as 
stertorous breathing, sighing and moaning, slow pulse, dark 
red and bloated face; or drowsiness, with confusion of the 
mind, and sense of heaviness and pressure within the head ; 
or else the opposite condition of wakefulness, with delirium } 
flushing of the face, scintillations before the eyes, humming in 
the ears, throbbing of the temporal arteries, spasms and con- 
vulsions. This remedy is especially indicated in those cases 
of cerebral hypersemia characterized by symptoms of depres- 
sion, and also in such as are caused by fright or debauchery. 

Phosphorus. — Heat and throbbing in the head, with vertigo ; 
buzzing in the ears ; swelling under the eyes ; emphysema ; 
palpitation of the heart; burning and stinging pains in the 
brain ; sense of weight in the forehead, increased by stooping ; 
heat in the vertex. Especially suited to chronic cases, with 
tendency to softening of the brain. 

Pulsatilla. — Oppressive, beating headache, with confusion of 
the mind ; red and bloated, or pale face ; scintillations before 
the eyes ; buzzing in the ears ; double vision ; vertigo ; drow- 
siness in the daytime and sleeplessness at night ; bitter, bilious 
taste in the mouth ; nausea or vomiting ; scanty or suppressed 
menses ; worse in a warm room, better in the open air. 

Rhus tox. — Heavy, reeling headache; shaking or wavering 
sensation in the brain, especially when walking ; burning, 



90 INTRACRANIAL DISEASES. 

throbbing pains in the head, with sense of fulness; vertigo 
when lying down ; red and burning, or pale and puffy face ; 
great restlessness, especially at night; pains aggravated by 
eating. Especially adapted to cases caused by cold, or when 
aggravated by damp weather. 

Veratrum vir. — Heat, fulness and sense of weight in the 
head, with violent throbbing of the carotid and temporal arte- 
ries ; flushed face ; ringing in the ears ; sensitiveness to light 
and sound ; double vision ; derangement of the stomach ; op- 
pressed respiration ; palpitation of the heart ; tingling and 
numbness in the limbs ; vertigo ; confusion of mind ; loss of 
memory; spasms and convulsions; congestions caused by 
teething, or by alcoholic stimulants. 



CEREBRAL APOPLEXY. 91 



CHAPTER III. 



CEREBRAL APOPLEXY. 



The term apoplexy, which is derived from a Greek word 
signifying "to strike," was originally used by the Greek writers 
to denote a sudden loss of consciousness and volition, with 
more or less disturbance of the circulation and respiration. 
Since the beginning of the present century it has been mainly 
confined to cerebral haemorrhage, for although the symptoms 
may be induced in other ways, haemorrhage into the brain is 
the most common cause of the apoplectic seizure. The term, 
however, is objectionable, when used to denote a particular 
disease or condition, partly because the group of symptoms to 
which it is applied is common to a variety of cerebral lesions, 
and partly because it has been used to denote haemorrhage into 
other organs, as the lungs, the kidneys, etc. As a consequence, 
the term is now seldom used to designate a definite lesion or 
disease, but any condition of the brain characterized by the 
following group or train of 

Symptoms. — In most cases the attack is preceded by certain 
premonitory symptoms, such as pain in the head, ringing in 
the ears, altered vision, vertigo, drowsiness, loss of memory, 
and other evidences of cerebral hyperemia, to which are 
sometimes added, more or less numbness and pricking in the 
extremities. In other cases no premonitory symptoms are 
present, but the patient, previously in apparent health, falls 
down insensible, with a total abolition of all the sensorial 
functions, or manifests a momentary apprehension of impend- 
ing danger, by raising his hands to his head and making some 
alarming sign or exclamation, at the very instant of falling. 
The degree to which the several functions are affected varies 
greatly in different cases. When very severe, sensation, con- 
sciousness, and voluntary motion, are all lost. In other cases, 



92 INTRACRANIAL DISEASES. 

there is a greater or less degree of senso-inotory impairment, 
the patient being in a state of semi-consciousness, sensible to 
outward impressions, and capable, to some extent, of voluntary 
movements. The pupils are at first generally contracted, 
frequently in an unequal degree, but in some cases they are 
largely dilated, and insensible to the stimulus of light. 

More or less paralysis is generally associated with the attack, 
however light the stroke. Usually, one side of the body is 
motionless, constituting hemiplegia. When paralysis exists, 
the tongue is turned towards the paralyzed side, the function 
of deglutition is lost or greatly impaired, the respiration is 
slow and heaving, and the breathing loud and stertorous ; there 
is also retention, or involuntary discharge, of urine and faeces. 
Though the power of voluntary motion in these cases is lost, 
there is sometimes more or less rigidity or spasmodic contrac- 
tion of the muscles, the symptoms being, as it were, of a mixed 
character, partly paralytic and partly spasmodic. 

The pulse is sometimes slow, full, and bounding ; at other 
times it is weak, small, and intermitting. In the former case, 
there is more or less heat and flushing of the face, with 
warmth of the extremities ; in the latter, on the contrary, the 
face is pale and sunken, and the extremities cold. 

"We have aimed to give, in the above description, only so 
much of the symptomatology of this affection as may serve for 
the easy recognition of what is known as the apoplectic state; 
but it should be remembered that the assemblage of symptoms 
to which the name is applied may be produced in various 
ways, and may or may not be complicated with paralysis. In 
order, therefore, to avoid unnecessary repetitions, and at the 
same time enable the reader to obtain a comprehensive view 
of the whole subject, we shall treat at length, in separate chap- 
ters (q. v.i. of each of the pathological conditions enumerated 
in the following list of 

Causes. — a. Cerebral Haemorrhage. 

b. Haemorrhage into the Cerebral Membranes. 

c. Embolism of Cerebral Arteries. 

d. Cerebral Hyperemia. 

e. Coup de Soleil. 

/. Ursemic and Alcoholic Intoxication. 



CEREBRAL HAEMORRHAGE. 93 



CHAPTER IV. 

CEREBRAL HEMORRHAGE. 

Syn. — Apoplexia Savguinia. 

By cerebral hemorrhage is meant the extravasation of blood 
from the cerebral vessels into the substance of the brain, or 
into its ventricles. The haemorrhage may take place from 
either the large cerebral arteries, such as the middle cerebral 
and basilar, or from the capillary vessels of the brain. It may 
spring from a single vessel or from several, and may be more 
or less in quantity, producing clots of various dimensions, from 
the size of a pea to that of an orange, and even larger. It may 
set in gradually or suddenly, and continue until it meets with 
sufficient resistance from the surrounding tissues to check the 
further effusion of blood, or it may take place by fits and 
starts, according to the varying degrees of pressure exerted at 
different times upon the cerebral vessels. 

There is no portion of the brain which may not be the seat 
of haemorrhage. As might be expected, however, cerebral 
haemorrhage occurs much more frequently in some situations 
than in others. Thus, in 579 cases reported by Gintrac, the 
cortical substance of the hemispheres was affected in 45; the 
anterior lobes of the brain in 17 ; the middle lobes in 127 ; the 
posterior lobes in 33 ; the corpora striata in 72 ; the optic 
thalami in 38 ; the crura cerebri and pons in 76 ; the cerebel- 
lum in 55, and the medulla oblongata in 2. 

Symptoms. — Occurring as it does under such a great variety 
of circumstances, the symptoms by which an attack of cerebral 
haemorrhage manifests itself, differ very much in different 
cases. They may, however, be divided into two classes, apo- 
plectic and paralytic. 



94 INTRACRANIAL DISEASES. 

In the majority of cases, the attack is preceded by premoni- 
tory symptoms of various kinds, such as severe paroxysms of 
pain in the head ; giddiness, especially when stooping or sud- 
denly turning the head ; flushings of the face, accompanied 
with coldness of the hands and feet ; frequent bleedings at 
the nose, particularly in elderly people; flashes of light before 
the e} 7 es ; paralysis of the external rectus muscle of the eye ; 
mydriasis; amblyopia from extravasations in the retinse; 
drowsiness; disinclination to work; neuralgic pains, involving, 
more particularly, the terminal branches of the ulnar nerve; 
twitchings of the muscles of the face, or some portion of the 
extremities, especially the fingers and toes ; numbness of one 
side of the body ; and sudden difficulty in speaking, in conse- 
quence of slight paralysis of the tongue, and other muscles con- 
cerned in articulation. 

A greater or less number of the above signs may exist for 
days and even weeks before the actual onset of the attack, but 
none of them affords any positive indication of the gravity of 
the haemorrhage. On the contrary, it often happens that in 
the apoplectic form of the disease they are wholly wanting. 
Whether present or absent, however, the attack is always more 
or less sudden in its onset. In a small number of cases, indeed, 
it may be absolutely sudden; but it much more frequently 
happens that the attack is immediately preceded by slighter 
symptoms, such as dizziness, noises in the head, dark specks 
before the eyes, tingling in the limbs, and thickness of speech. 

In well-marked cases, the patient, if standing, suddenly 
staggers, falls, and at once becomes unconscious. Examining 
the patient, we now find that, although the functions of circu- 
lation and respiration continue to be performed, he is insen- 
sible to stimulation, and is paralyzed on one side of the body. 
His senses are so far extinguished that neither loud sounds, 
bright lights, nor substances having a strong and disagreeable 
smell or taste, make any impression on the brain. The face is 
livid, swollen and distorted, or pale and corpse-like. The 
breathing is slow and stertorous ; the cheeks are flabby, and 
protrude during expiration ; the mouth is more or less open, 
and is drawn towards the non-paralyzed side ; the eyelids are 



CEREBRAL HAEMORRHAGE. 95 

closed; the conjunctiva injected and insensible; the eyeballs 
fixed ; the pupils sluggish, but variable as to size, being gener- 
ally dilated, but sometimes contracted or unequal, according 
as the nerves of the iris are irritated or paralyzed. 

If the haemorrhage be great, or the attack very severe, the 
lower sphincters are more or less paralyzed, and all control 
over the urine and faeces is lost. The reflex excitability of the 
spinal cord is generally increased, owing to the fact that the 
inhibitory influence usually exerted by the brain is removed. 
Thus, if the sole of the foot be tickled, the leg will be drawn 
up, or jerked to one side. 

Such is the general condition of the patient when the extra- 
vasation takes place into the corpus striatum and optic thala- 
mus; when it opens into the meninges or the lateral ventricles, 
the limbs of one side are spasmodically affected, being either 
contracted or convulsed. 

An apoplectic attack of this character may result in death 
within a few days, a few hours, or even a few minutes, accord- 
ing as the lesion is more or less severe. When slight, the apo- 
plectic condition may last not more than half an hour or so. 
In other cases it may disappear more gradually, accompanied 
with symptoms denoting the return of consciousness. In fact, 
as there is every degree of injury and of shock in these cases, 
so there is every sort of gradation between the deepest coma 
and mere mental confusion — conditions which manifest them- 
selves by various degrees of stupor, delirium, and mental inco- 
herence. For example, when consciousness begins to return, 
if spoken to loudly, the patient may open his eyes, turn over 
in bed, or attempt to speak; or be may simply raise his eye- 
lids for a moment without taking any further notice ; or he 
may answer "yes " or " no," and again lapse into stupor. 

Other symptoms also manifest themselves in different cases, 
or in different stages of the same case, according to the gravity 
of the attack. The movements of respiration and circulation, 
instead of being slow and regular, as at first, frequently become 
irritated and irregular. Thus, the breathing becomes short 
and superficial ; or, having been accelerated, it becomes re- 
tarded and intermitting. Under these circumstances the air- 



96 INTRACRANIAL DISEASES. 

passages become more or less obstructed with mucus; and a 
mixture of mucus and saliva escapes from the half-open mouth. 

But one of the most important and peculiar symptoms is the 
variation in the animal temperature. At first it undergoes a 
marked reduction, the thermometer in the rectum indicating, 
in most cases, a temperature of 96° or 97°F. This reduction 
appears to correspond to the continuance of the haemorrhage. 
After the latter has ceased, the thermometer generally rises to 
about the normal standard (99.4°-101°), at which point, if the 
patient is to recover, it remains nearly stationary. But when 
the haemorrhage is very extensive, or there is an unusual fall 
of temperature at the commencement, the mercury again rises, 
and this time may reach an elevation of 103°, 105°, and even 
107°F., indicating a fatal termination. 

Another peculiar symptom sometimes observed in these 
cases is, the conjugated or conjoint lateral deviations of the eyes and 
head towards the sound side. This deviation is sometimes seen 
during the period of unconsciousness, but it may continue 
afterwards, the patient after his return to consciousness having 
no power to correct it. By great effort he may succeed in 
turning the head in the opposite direction, but not the eyes. 
This symptom is not due to paralysis, but to spasm, excited 
partly by irritation of the third cerebral nerve, which produces 
internal deviation on the side opposite the lesion ; partly by 
irritation of the sixth nerve, which causes external deviation 
on the same side ; and partly by irritation of the eleventh, or 
spinal accessory nerve, which, by producing contraction of the 
sterno-mastoid muscle, causes the deviation of the head. Alt- 
haus says that this symptom always denotes a sudden and 
extensive injury to the brain, which, mostly proves fatal; but 
Hammond declares that he has met with the deviations in 
about one-third of his cases of cerebral haemorrhage, having 
been present from the beginning, and that they disappeared 
in a few days. 

Should the patient live to reach the second stage of the dis- 
ease, a different set of symptoms, characteristic of the period of 
inflammation, generally supervenes. This period usually sets 
in about the eighth or ninth day after the occurrence of the 



CEREBRAL HEMORRHAGE. 97 

extravasation, with symptoms of cerebral fever, such as restless- 
ness, pain in the head, delirium, convulsions, nausea and vom- 
iting. This stage may last from three or four days to a week, 
and then terminate, either in death, or, by a gradual abate- 
ment of the symptoms, in resolution. In the latter case, the 
mind becomes every day more and more clear, articulation 
more distinct, and movement of the paralyzed limbs more free 
and easy. For some reason, the leg usually recovers its power 
much sooner than the arm, so that the patient is often able to 
walk about long before he can make any use of the upper ex- 
tremity. When, as sometimes happens, the arm regains its 
power before the leg, the termination is usually fatal. 

An acute bed-sore sometimes forms over the gluteal region of 
the paralyzed side, and occasionally, but very rarely, over that 
of the sound side. This acute sloughing process, which occurs 
quite independently of pressure, or of any external irritating 
influence, may begin to manifest itself within three or four 
days after the apoplectic seizure. It commences in the form 
of an erythematous spot, or macula, which is soon succeeded 
by the appearance of bullae filled with colorless serum, which 
afterwards becomes sanguinolent. The raised cuticle soon 
gives way, and is followed by a gangrenous condition of the 
part, which spreads so rapidly that the patient seldom lives 
long enough for the slough to separate ; indeed, according to 
Charcot,* the lesion is one that almost invariably indicates a 
fatal termination of the case. 

After the acute symptoms have subsided, that is to say, in 
about ten or twelve days after the occurrence of the haemor- 
rhage, there remains either complete hemiplegia, or a degree 
of paralysis corresponding to the locality and extent of the 
central lesion. When the entire corpus striatum is involved, 
there is complete paralysis of the opposite side of the body. 
In most cases, however, the paralysis is incomplete, the mus- 
cles which escape being those of the eye, neck, back, and chest. 
This incomplete form of facial paralysis readily distinguishes 
cerebral palsy from facial paralysis, properly so called. In the 

* Arckiv. de phys., 1868. 
7 



98 INTRACRANIAL DISEASES. 

latter affection it is utterly impossible for the patient to close 
his eye on the paralyzed side, whereas in the cerebral form he 
can shut it with apparent ease. He cannot, it is true, close 
the lids as firmly as he can those of the opposite eye, nor can 
he close the eye of the affected side without shutting that of 
the sound eye at the same time; at least he can only do so 
with great difficulty. Moreover, the muscles which chiefly 
suffer in these cases are those of mastication, so that when the 
patient attempts to close the jaw, the temporal and masseter 
of the sound side contract more energetically and promptly 
than those of the affected side. Other facial muscles are like- 
wise implicated, rendering the cheek flabby, the nostril con- 
tracted, and the lip depressed and drawn towards the healthy 
side. 

Owing to the peculiar action of the genio-glossus muscle, 
the tongue, in most cases of cerebral paralysis, deviates towards 
the paralyzed side. In a few cases, however, the tip of the 
tongue is turned towards the sound side, the lesion being 
in the medulla oblongata, below the point w T here its fibres 
decussate. 

The diaphragm and muscles of the back are not affected in 
cerebral haemorrhage, but the straight muscles of the abdomen 
appear to be weakened on the paralyzed side, as is seen when 
the patient attempts to assume the sitting posture by the aid 
of these muscles. 

As before stated, the upper extremity is more profoundly 
paralyzed than any other part. The movements of abduction 
and adduction, flexion and extension, pronation and supi- 
nation, are all rendered impossible. Unless improvement 
speedily sets in, contractions of the paralyzed muscles soon 
take place, the flexor muscles being generally more affected 
than the extensors. Not only the muscles of the arm, but 
those of the wrist and fingers suffer from contraction or 
paralysis. The flexors of the fingers are sometimes so forcibly 
contracted as to irritate the palm. 

The lower extremity is at first as much affected as the upper, 
but it generally recovers more quickly from the paralysis. 
The flexor muscles of the paralyzed leg are apt, however, to 



CEREBRAL HEMORRHAGE. 99 

remain somewhat contracted in these cases, causing the patient 
to limp more or less in his walk. 

As might be expected, most voluntary movements are more 
or less imperfectly executed for a considerable period after the 
attack. At times, indeed, especially when under the influence 
of strong excitement, the patient may be able to perform or- 
dinary movements with facility; but until the muscular power 
has fully returned, they are made in a more or less awkward 
and difficult manner. 

In some cases the paralyzed limbs become permanently 
contracted. This was formerly thought to be due to secondary 
encephalitis, but Charcot, Tiirck, and Vulpian have shown it 
to be the result of certain secondary changes in the nervous 
centres, especially sclerosis of the lateral columns of the spinal 
cord. This late rigidity of the paralyzed muscles differs from 
the early rigidity, not only by the lateness of its appearance, 
but by being both progressive and permanent. 

Causes. — The chief predisposing causes of cerebral haemor- 
rhage are inheritance and old age. Statistics show that it occurs 
in the descendants of apoplectic parents much more frequently 
than in others, owing either to a similarity of physical con- 
formation, or, which is more probable, to some inherited weak- 
ness of the system, the existence of which in the parents con- 
stitutes the original predisposition to the complaint. Thus, 
Piorry mentions the case of a woman, three of whose children 
had died of convulsions, while she herself was a paralytic, 
and her mother, uncle, brothers and sisters, to the number of 
twelve, had all died, either of cerebral haemorrhage or of con- 
vulsions. 

Old age, however, is the principal predisposing cause, and 
is doubtless the most powerful, as the great majority of cases 
occur after the age of forty. The greatest number of deaths 
from cerebral haemorrhage occurs at about the age of seventy 
years, after which the number diminishes, but not the ratio. 
Hence, people advanced in life, especially if they are, or have 
been, very hard thinkers, or addicted to excesses of any kind, 
are very apt to be cut off in this manner. For these reasons, 
probably, women, whose habits of life are generally more 
regular than those of men, are less liable to the disease. 



100 INTRACRANIAL DISEASES. 

Cardiac affections were formerly supposed to favor the dis- 
ease by causing more or less congestion of the brain, and when 
other circumstances concur to produce this condition, such as 
granular degeneration of the kidney, which leads to increased 
tension in the cerebral vessels, no doubt they contribute to 
the result. But ordinary hypertrophy of the left ventricle from 
disease of the aortic valves, instead of causing cerebral haemor- 
rhage, can at most merely compensate for the imperfect closure 
of the valves, without increasing the force of the cerebral 
circulation, and consequently without endangering the rupture 
of cerebral blood-vessels. 

Very cold weather undoubtedly favors the production of the 
disease, as cerebral haemorrhage is much more common in 
midwinter than in summer.. The same is also true of sudden 
variations of temperature, especially from mild to cold weather. 

The exciting causes Of cerebral haemorrhage are quite numer- 
ous, but they may be reduced to a very few classes, viz., to what- 
ever tends to produce congestion of the brain ; such as violent 
mental emotions, long exposure to the direct rays of the sun, 
heavy lifting or straining, hard coughing or vomiting, sexual 
intercourse, playing upon wind instruments, childbirth, the 
free use of alcoholic stimulants, compression of the vessels of 
the neck, dependent position of the head in stooping, etc. To 
these may be added, repelled eruptions, an overloaded state of 
the stomach, the sudden suppression of habitual discharges, 
long exposure to extreme cold, and an unhealthy state of the 
blood, such as exists in chlorosis, scurvy, typhus, syphilis, etc. 

Diagnosis. — Cerebral haemorrhage is liable to be confounded 
with both syncope and coma. In syncope, however, the sur- 
face is pale and cold, the features are contracted, the pulse is 
lost at the wrist, and the respiration is temporarily suspended 
— symptoms the very reverse of those usually met with in 
cerebral hemorrhage. Coma is a frequent accompaniment of 
various diseased conditions, and can only be differentiated by 
the cause, which, in cases of cerebral haemorrhage, generally 
depends upon sudden pressure on the brain, while in other 
cases it is symptomatic of asphyxia, narcotic or uraemic poison- 
ing, inebriation, cerebral concussion or inflammation, hysteria, 



CEREBRAL HEMORRHAGE. 101 

etc. Coma may also result from embolism, thrombosis, men- 
ingeal haemorrhage, tumor, or abscess; but in these cases the 
diagnosis is generally more or less uncertain and difficult. 

In case, however, a young person suffering from disease of 
the left side of the heart suddenly becomes unconscious, the 
probability is that the attack is due to cerebral embolism. 
The probability is considerably increased if the resulting 
hemiplegia occurs on the right side, as embolism in the brain 
is most frequently met with in the left middle cerebral artery 
or in some of its branches. 

Cerebral haemorrhage and thrombosis bear a close resem- 
blance to each other, since they have a great tendency to occur 
in elderly people, and each is liable to be preceded by pre- 
monitory signs; but the development of the symptoms in 
thrombosis is generally much slower than in haemorrhage, or 
in embolism; so that when the attack occurs in an elderly 
person, and is preceded by long-continued and well-marked 
prodromata, and especially if the arteries are rigid and the 
cardiac pulsations weak, we are justified in referring the attack 
to thrombosis. 

As for cerebral tumors or abscesses, the symptoms, like those 
in thrombosis, are not only gradual in their development, but 
are frequently of an epileptic character. A fixed pain in the 
head is generally one of the most prominent symptoms; and 
the paralysis, although unilateral, is frequently limited to one 
or more of the cerebral nerves. Moreover, the symptoms, in- 
stead of gradually diminishing, as in cerebral haemorrhage, 
become, as a general rule, more and more pronounced. 

Cerebral haemorrhage may be distinguished from asphyxia 
by the fact that in the latter the respiration is suspended. 
Moreover, the cause which suspends the respiratory move- 
ments, whether it be mechanical injury, strangulation, drown- 
ing, or the inhalation of noxious gases, is generally plainly 
manifest. 

The comatose state of an epileptic paroxysm closely resem- 
bles that of an apoplectic seizure due to cerebral haemorrhage, 
but the stupor of epilepsy is not usually accompanied by ster- 
torous breathing, nor is it often of long duration. Moreover, 



102 INTRACRANIAL DISEASES. 

if the comatose condition is the result of an epileptic paroxysm, 
more or less froth, often colored with blood from a bitten 
tongue, may be found upon the lips, and not unfrequently 
small spots of extravasated blood may be seen under the skin 
of the forehead, e} r elids, and cheeks. 

Concussion is liable to be mistaken for cerebral haemorrhage, 
unless the patient has received mechanical injuries of such a 
nature as to show that the symptoms are the result of a fall or 
blow, such as bruises, fractures, bleeding from the nose or ears, 
etc. It is possible, however, that the fall may have been the 
consequence of a haemorrhage within the brain, in which case 
he may appear to be suffering from simple concussion when 
the chief injury is one of compression, perhaps complicated 
with fracture of the cranium. 

Hysterical coma sometimes bears a very close resemblance 
to that of cerebral haemorrhage, and may even be accompanied 
by well-marked hemiplegia; but in these cases there are gen- 
erally other evidences of the hysterical condition present, such 
as the hysterical constitution, an unembarrassed state of the 
circulation, freedom from stertor, etc. 

Uraemic coma is distinguished from the coma of cerebral 
haemorrhage, by the history of the case, the absence of hemi- 
plegia, the altered state of the urine, and the general presence 
of anasarca. 

Alcoholic intoxication is frequently confounded with cerebral 
haemorrhage, much to the discredit of the profession; though 
it must be confessed that the resemblance between the two 
conditions is sometimes so great as to render it extremely dif- 
ficult to make a satisfactory diagnosis. When, with the usual 
signs of inebriety, there is neither hemiplegia nor stertor, it 
will generally be safe to attribute the symptoms to drunken- 
ness, especially if the habits of the patient are of a character 
to warrant such a conclusion. 

Prognosis. — Cerebral haemorrhage is always a very danger- 
ous disease; so much so, that it is generally impossible, soon 
after the attack, to determine the result with any degree of 
accuracy. As a general rule, however, it may be stated that 
the danger to life is in proportion to the severity of the seizure; 



CEREBRAL HEMORRHAGE. 103 

and in the severe apoplectic form the disease is almost always 
fatal within a few hours. If, however, life be prolonged three 
or four days, there is some degree of hope. Among the more 
important signs threatening a fatal issue, are: protracted coma, 
convulsions, general paralysis, dilated pupils, obstructed res- 
piration, foaming at the mouth, frequent vomiting, coldness 
and clamminess of the surface, and involuntary evacuations. 
Still, if the vital powers are husbanded, the patient may pos- 
sibly survive even these formidable symptoms, though it must 
be confessed, that if the patient escape for the time, he is very 
liable to sink sooner or later, either from a recurrence of the 
attack, or by a general failure of the vital powers resulting 
from the injury done to the brain. If, however, the patient 
survive the first onset of the disease without any subsequent 
aggravation of the symptoms, there will always be room for 
hope, even when the extravasation of blood is extensive. But 
it should always be remembered that about the eighth or ninth 
day of the seizure is a critical period, for then inflammation 
sets in about the clot and may destroy the patient. 

Not more than one in three of the cases attended with coma 
and hemiplegia survives the attack; whilst few if any can be 
said to fully regain their health. Each succeeding attack 
leaves the system less capable of enduring a renewal of the 
haemorrhage, so that finally the mental faculties, the power of 
speech, and the coordination of movements, are more or less 
defective. Besides, relapses are common, the disease being, as 
a rule, progressive in its nature. Consequently, although the 
patient may survive the second, third, and even fourth attacks, 
both the mental and physical powers suffer a gradual decay 
from secondary atrophy, which, as before stated, sooner or 
later terminates in death. 

Mild forms of the disease, however, especially such as are not 
attended with loss of consciousness, are not generally fatal, 
though the risk of inflammation excited by the clot is so great, 
that the patient cannot be considered out of danger, even in 
these cases, until after the eighth or ninth day of the seizure. 

Morbid Anatomy. — When the blood escapes into the sub- 
stance of the brain, it forms one or more cavities by the sepa- 



104 INTRACRANIAL DISEASES. 

ration or laceration of the cerebral fibres, the haemorrhage con- 
tinuing until the resistance of the tissues becomes so great as 
to overcome the tension of the effused blood, when it ceases. 
The resulting cavities, and consequently the clots, differ greatly 
in size and shape, being round, oval, or irregular in form, and 
varying in diameter from that of a hazelnut or cherry to that 
of an orange. There is generally only one cavity and clot, 
though there may be several. In the former case, the clot is 
usually large, and occupies some portions of the grey matter. 

Most cases of cerebral haemorrhage result from rupture of 
the small branches of the middle cerebral artery. The blood 
penetrates the substantia perforata lateralis, and, pushing 
aside the optic thalamus, ruptures the corpus striatum, and 
finally invades the lateral, and sometimes the third and 
fourth ventricles. 

Next in order of frequency comes the optic thalamus. In 
more than half of the cases collected by Andral, the haemor- 
rhage took place into either the corpus striatum or the optic 
thalamus, or else into both. In about fifteen per cent, of the 
cases it occurred in the corpus striatum alone ; and in about 
seven per cent, of them in the thalamus opticus alone. We 
have already given Gintrac's statistics, in which it will be seen 
the corpus striata and optic thalami were found to be simulta- 
neously involved in nearly nine per cent, of the whole number 
of cases. 

Owing to pressure of the clot, the convolutions are often 
found flattened, the blood-vessels empty, and the cerebral tis- 
sue pale and anaemic. In most cases, the clot is mixed with 
debris of the cerebral matter, and the brain-tissue surrounding 
it is more or less softened. If the patient survive the stroke, 
the blood corpuscles and nerve-fibres undergo fatty degenera- 
tion, the effused serum is absorbed, and the fibrinous debris 
contracts and becomes hard, changing gradually from a black 
to an ochre color. Examined with the microscpe, the altered 
matter is found to contain granulations of haematosin and 
crystals of haematin and haematoidin. In some few instances, 
however, absorption fails to take place, and the cavity 
remains distended with blood until a new haemorrhage occurs, 



CEREBRAL HEMORRHAGE. 105 

or an abscess results. The condition of the blood-vessels will 
be given under the head of 

Pathology. — The investigations of MM. Charcot and 
Bouchard leave little room for doubt, that cerebral hsemor- 
rhage is generally due to what they term miliary aneurisms. 
These minute aneurisms form upon the smaller branches of 
the cerebral arteries, in consequence of an inflammatory con- 
dition which results in atrophy of their middle coat, on which 
their power of resistance chiefly depends. These dilatations 
vary in size from a millet seed to that of a large pin-head. 
They adhere to the perivascular sheath ; and when ruptured 
they sometimes heal spontaneously by the formation of a clot 
in them, which afterwards undergoes degeneration. They are 
usually very numerous, and have been found in all parts of 
the brain ; in the fissures between the convolutions, in the 
white substance of the hemispheres, in the basal ganglia, in 
the cerebellum, and in the pons Varolii. They are not, how- 
ever, confined to the brain, but have been discovered in the 
central artery of the retina, in the oesophagus, on the visceral 
layer of the pericardium, and in the branches of the splenic 
artery. Nothing is positively known as to their origin, but it 
is reasonable to suppose that they owe their formation either 
to hereditary influences, or to debilitating causes, such as in- 
temperance, malnutrition, and old age. 

But although miliary aneurisms may, in the great majority 
of cases, be said to constitute an important factor in the pro- 
duction of cerebral haemorrhage, they are not the only form of 
vascular disease existing in these cases; for not only is athe- 
romatous degeneration of the cerebral blood-vessels a common 
pathological condition in the aged, but cases of cerebral haemor- 
rhage have been observed in which this condition affected all 
the arteries of the brain, while at the same time no miliary 
aneurisms were anywhere present. 

Other conditions doubtless favor the rupture of cerebral 
blood-vessels, such as an increased tension of the blood in the 
vessels; an unhealthy state of the blood, such as exists in 
typhus, scurvy, etc., rendering it unfit for the nourishment of 
the blood-vessels; atrophy or softening of the brain substance; 



106 INTRACRANIAL DISEASES. 

and the various deteriorating influences mentioned under the 
head of causes. 

Treatment. — The treatment of cerebral haemorrhage is 
three-fold, preventive, palliative, and curative. 

1. Preventive Treatment. — The preventive treatment consists 
in the avoidance, as far as practicable, of the ordinary causes 
of cerebral hsemorrhage, and the administration, when re- 
quired, of the remedies recommended for cerebral hypersemia 
(q. v.). 

2. Palliative Treatment— -The palliative treatment of cerebral 
haemorrhage consists in the application of such auxiliary 
measures, and the observance of such hygienic regulations, as 
are calculated to lessen the effects of the injury and promote the 
welfare of the patient, especially at the time of the stroke and 
during the period of unconsciousness. Thus, the patient 
should be kept in such a position as will favor the return of 
blood from the head. The head and shoulders should be 
raised by pillows, the clothing loosened about the neck, and 
free ventilation of the patient's chamber constantly secured. 
The lower extremities, and especially the paralyzed limbs, 
should be kept warm by means of flannel wrappings, frictions, 
etc.; and the bowels should be emptied from time to time with 
lavements of tepid water, to which may be added, if necessary, 
a tablespoonful or two of castor oil. Attention should be paid 
to the bladder, and the urine drawn off regularly with the 
catheter, until the patient becomes able to void it voluntarily. 

The diet is also an important matter. In the early stages 
of the attack, nothing but gum-water, barley or rice-waier, 
toast-water, and similar farinaceous drinks, should be allowed; 
but as the case advances, and improvement sets in, more nu- 
tritious substances may be cautiously administered, such as 
milk, beef-tea, soft-boiled eggs, etc., provided no ill effects are 
thereby produced; but if, on strengthening the diet, the face 
becomes flushed and headache ensues, all stimulating and 
highly nutritious articles of food should be immediately with- 
drawn. If symptoms of inflammation set in, the treatment 
recommended for meningitis and encephalitis should be ob- 
served. 



CEREBRAL HAEMORRHAGE. 107 

3. Curative Treatment. — The curative treatment consists, first, 
in the administration, as required, of the remedies specially 
indicated by the symptoms; and, secondly, in the removal, as 
far as possible, of the secondary effects of the injury, especially 
the paralysis and anaesthesia. 

No attempt, however, should be made to overcome the pa- 
ralysis until the brain symptoms have entirely disappeared, 
nor until the period of inflammation has fully past. It will 
then be proper, in most cases, to take measures for the relief 
of the paralysis, and for the prevention of muscular contrac- 
tions. For these purposes, in addition to the indicated reme- 
dies, we may make use of massage and electricity. The former 
is accomplished by kneeding the affected muscles with the 
fingers, and by flexing and extending the joints every day for 
ten, fifteen, or twenty minutes at a time. 

But the most successful treatment for hemiplegia, aside 
from medicine, is electricity. At first, or in recent cases, the 
induced current will usually be found to afford sufficient stim- 
ulation for the purpose. The current, which should be strong 
enough to produce contraction, or to cause slight pain, should 
be applied by means of wet sponges to the skin covering the 
muscles, or, if necessary, to the nerves. Old cases, and such 
as will not yield to the induced current, should be treated 
with the primary current, applied in such a manner as to be 
interrupted, as the constant current will not produce contrac- 
tions. Electricity is also a potent agent in promoting the 
restoration of sensibility, in cases in which the anaesthesia 
does not disappear spontaneously. 

Dr. Hammond extols the use of strong magnets in the treat- 
ment of the hemiplegia resulting from cerebral haemorrhage. 
In one of two cases in which he employed this agent, the 
paralysis and hemianaesthesia disappeared within half an 
hour; and in the other the hemianesthesia was overcome in 
less than five minutes. He made use in these cases of a mag- 
net capable of sustaining ten pounds of iron, simply laying it 
against the paralyzed side of the body. 

General Indications. — Premonitory symptoms. — Aeon., Amyl 
nit,, Bell., Cham., Gels., Glon., Hyos., Phos., Sepia, Strain., 
Yerat. vir. 



10 S NIAL DISEASES. 

« 

During the attack. — Aeon.. Arn.. Bell.. C ecul., B 

Lach., Lauroc. Xux v., Opium, Merc Sanguin. 

Sub» changes. — Anacard.. Caust.. Cupr., Kali, 

Plumb., Rhus, Strain., Zineum. 

Special Indication — A — Inflammatory stage, or when 

the head is hot. the carotids throbbing, the pulse full, hard 
and strong, or weak, but not intermittent, the skin hot or 
warm, but not cold, and especially when caused by suppre- 
ha?niorrh: iges i after fright or vexation. 

— Drowsiness :th moaning and insensibility: eyes 
staring or dim; pupils dilated or contracted: pulse irregular, 
intermittent, or full and strong; respiration labored and snor- 
ing; involuntary evacuations of fseees and urine; paralysis, 
especially of the left side. This remedy is particularly suited 
to stout, middle-aged, plethoric people, with strong hemor- 
rhagic tendencies. 

Baryta. — Drowsiness, with semi-consciousness, in old people: 
dimness of sight : breathing short and suffocative : pulse small 
and irregular: anxiety, fear, and loss of memory: great rest- 
lessness and moaning ; paralysis of the tongue : general paralysis, 
especially of the right side; frequent discharges of urine and 
faeee- Especially suited to old people, particularly those ad- 
dicted to the excessive use of alcoholic drinks. 

Belladonna. — During the first, or con^ : t stage, during 
the period of stupefaction, and also during the inflamma: i 
period; drowsiness or loss of consciousness, with dilated pu: ils 
slow and full pulse, labored, irregular, and stertorous breath- 
ing: or, red and staring eyes, with redness of the face and icy 
coldness of the extremities : convulsive movements: paral; psis 
of the tongue, limbs, etc.; involuntary discharges of faeces and 
urine; dysphagia; wandering s of the mincL 

Cocculus. — Strong determination of blood to the head, fol- 
lowed by drowsiness, vertigo, and loss of consciousness: dim- 
ness of vision; pupils greatly dilated or contracted, -vith 
spasmodic rolling of the eyeballs: pulse small and hard; 
breathing tight and oppressed, with or witho ; stertor; con- 
vulsions and paralysis, esj e daily of the lower extremities 



CEREBRAL HAEMORRHAGE. 109 

Lachesis. — Congestion to the head, with blueness of the face; 
absence of mind when conscious; drowsiness, or sopor and in- 
sensibility; dim and distorted eyes; pulse small, weak and 
irregular, or full and hard; slow, heavy, wheezing respiration; 
trembling of the muscles, or paralysis, especially on the left 
side; when caused by mental emotions or the abuse of liquors. 

Laurocerasus. — Patient speechless when conscious, or insensi- 
ble, with complete loss of consciousness and sensation; bloated 
face; eyes distorted and staring; vision completely lost; pupils 
dilated or contracted, and immovable; pulse very small, slow 
and irregular; convulsions, with subsequent paralysis, includ- 
ing paralysis of the sphincters ; great coldness, with clammi- 
ness of the surface, and deficient susceptibility to the action of 
remedial agents. 

Mercurius. — Constipation, followed by vertigo and loss of 
consciousness; dilatation of the pupils, with vanishing of sight; 
dyspnoea; feeble, slow, and trembling pulse; urine suppressed, 
or dark and turbid; great sinking and prostration; spasmodic 
movements of the limbs; paralysis, preceded by formication 
and followed by contractions. 

Nux vom. — Attacks preceded by constipation and high living, 
or by premonitory symptoms, such as vertigo, headache, roar- 
ing in the ears, etc.; sopor, with snoring; eyes dull and blurred; 
pulse full and hard, or small and weak; suffocative fits, or 
anxious dyspnoea; retention of urine; paralysis, especially of 
the lower limbs and lower jaw; cold extremities. 

Opium. — Coma, preceded by headache, vertigo, and other 
evidences of cerebral congestion ; pupils dilated, and insensible 
to light ; pulse slow, full or weak, and intermittent ; retention, 
or involuntary evacuation of urine; red and bloated face; 
trembling of the muscles; convulsive movements; dropping 
of the lower jaw; tetanic rigidity of the whole body ; head hot, 
with cold sweat; foam at the mouth; respiration slow, heavy 
and snoring. 

Pulsatilla. — Loss of consciousness, preceded by drowsiness, 
and occurring at the climacteric period, or preceded by an 
arrest or disturbance of the menstrual function ; eyes dull and 
bleared ; pulse almost imperceptible ; respiration impeded and 



110 INTRACRANIAL DISEASES. 

rattling ; retention or incontinence of urine ; red and bloated 
face; violent palpitation of the heart; great weakness and 
trembling, followed by loss of motion. 

Sanguinaria. — Attacks caused by venous congestion ; burn- 
ing heat and redness of the face ; distension of the temporal 
veins ; sharp pain in the back of the head ; dizziness on 
quickly turning the head ; burning of the ears ; paralysis of 
the right side. 

, Sepia. — Attacks preceded by venous congestion, or by deter- 
mination of blood to the head ; headache coming on with 
flashing pains; vertigo when walking; intermitting pulse; 
cold feet ; absence of mind ; palpitation of the heart ; jerking 
of the limbs ; sudden stoppage of the menses. Especially 
adapted to women at the climacteric period, and to men ad- 
dicted to drinking and venery. 

Stramonium. — Vertigo, followed by stupor and insensibility; 
pupils dilated and insensible; pulse small, irregular, and 
almost extinct; deep, stertorous breathing; involuntary emis- 
sions of urine ; spasmodic rigidity and trembling ; stupefaction 
alternating with delirium ; convulsive movements ; paralysis, 
especially of the organs of speech. 

Zincum met. — Attacks preceded by stupefying headache, 
with great drowsiness, cold hands and feet, and livid face ; 
stupor, with vanishing of sight ; quick and irregular, or slow 
and weak pulse; weakness, heaviness, and trembling of the 
limbs; anxious dyspnoea; palpitation of the heart; jerking 
and twitching of the muscles ; senses remain disturbed after 
the attack ; symptoms aggravated by wine. 



THROMBOSIS OF CEREBRAL VESSELS. Ill 



CHAPTER V. 

« 

THROMBOSIS OF CEREBRAL VESSELS. 

By Cerebral Thrombosis is meant the gradual closure of a 
blood-vessel in the brain, by the deposition of fibrine upon its 
internal surface. It differs from embolism (1) in the clot origi- 
nating in the blood-vessel itself, instead of being carried into 
it from a distance ; (2) in being either venous or arterial ; and 
(3) in being gradual instead of sudden in its development, 

Symptoms. — The gradual occlusien of a cerebral vessel by 
a thrombus, gives rise to a large number of initiatory symp- 
toms, such as headache, vertigo, impaired memory, difficulties 
of speech, ocular troubles, diminished sensibility on one side 
of the body, tottering gait, and other evidences of approaching 
paralysis. These symptoms, however, are often interrupted by 
periods of apparent improvement; and even after paralysis 
sets in, the loss of power in the muscles of the face, arm, or leg, 
is not only gradual in its advance, but is interrupted by stages 
of remission, until at last the vessel is completely blocked up, 
when hemiplegia supervenes. Even then, unless speedily fol- 
lowed by death, improvement is likely to occur, and may con- 
tinue for a considerable period ; but as the disease is progres- 
sive, the attack is almost certain, sooner or later, to be repeated. 

The symptoms vary in different cases, according to the seat 
and extent of the lesion. When considerable, as where a large 
vessel or a number of small ones are closed, the paralysis is 
progressive, and is accompanied with muscular contractions 
and mental torpor. As in embolism, when the left middle 
cerebral artery is plugged, right hemiplegia with aphasia is 
produced ; whereas, if the same artery on the right side is oc- 
cluded, there will be left hemiplegia, but no aphasia. 



112 INTRACRANIAL DISEASES. 

"What is called marantic thrombosis, or that form which occurs 
in the condition known as marasmus, is most frequently seen 
in weakly infants, especially after exhaustive attacks of diar- 
rhoea. In these cases, there is generally more or less rigidit} r 
of the muscles of the neck, back, and extremities ; and in some 
instances ocular troubles are present, such as ptosis, strabis- 
mus, and nystagmus. There is also, as in hydrocephaloid, 
cerebral ^seinia, followed by somnolence and coma; but these 
are not generally preceded, as in acute hydrocephalus, by 
marked excitement and convulsibility. Here the superior lon- 
gitudinal sinus is the seat of the thrombus. 

In adults, the symptoms of venous thrombosis are not usu- 
ally so well marked. There is generally, however, more or 
less headache, and mental and physical depression ; changes 
in the size of the pupils are also not uncommon ; and in some 
cases there is nausea and vomiting, swelling of the veins which 
communicate with the affected sinuses, more or less oedema, 
trembling of the limbs, and even convulsions. Thus, when 
the superior longitudinal sinus is involved, we have swelling 
of the veins of the auricular and temporal regions, together 
with epistaxis from congestion of the veins of the nose. Thus, 
also, thrombus of the transverse sinus leads to oedema behind 
the ear ; and thrombus of the cavernous sinus, which commu- 
nicates with the ophthalmic veins, frequently causes a bulging 
of the eye between the lids, which are oedematous, and also 
hyperasmia of the fundus oculi. 

Causes. — Whatever impedes the flow of blood in the cere- 
bral vessels may lead to the formation of thrombi, not only in 
the cerebral veins and sinuses, but in the arteries. Hence, we 
find that coagulation of blood in the vessels of the brain is 
most apt to occur in debilitated states of the system, as in the 
advanced stages of tuberculosis and cancer; after typhus and 
other low fevers; exhausting diarrhoeas, especially in young 
children; chronic inflammation of the joints; diffuse suppu- 
rations; caries; syphilis; atheromatous degeneration in the 
aged and decrepid ; cardiac debility ; pressure from tumors 
and effusions, and other like causes. It has also been attrib- 
uted to other agencies, such as exposure to intense heat, 



THROMBOSIS OF CEREBRAL VESSELS. 113 

severe mental strain or shock, and suppression of the menses ; 
and there can be no doubt that blows on the head produce it, 
by exciting phlebitis in the sinuses of the dura mater. 

The disease is much more common in males than in females, 
probably because the former, in consequence of exposure, are 
more subject to rheumatism, which seems to favor the disease 
by increasing the amount of fibrine in the blood, and also by 
impairing the action of the heart. 

Diagnosis. — Cerebral thrombosis may be distinguished from 
cerebral haemorrhage by the gradual development of the symp- 
toms; from encephalitis by the absence of fever; and from both, 
by the previous history of the case. It may be distinguished 
from embolism by (1) its slow development; (2) the advanced 
age of the patient; (3) the evidences of atheroma, fatty degen- 
eration of the heart, slight attacks of paresis or paralysis, and 
other characteristic symptoms; and (4) the absence, in most 
cases, of any previous history of rheumatism. 

Prognosis. — The prognosis in cerebral thrombosis is un- 
favorable, not only because the conditions which lead to it are 
of an unfavorable character, but because the disease is pro- 
gressive, and the danger of complete obliteration very great; 
in which case the probability that the collateral circulation 
will become sufficiently established to prevent softening is very 
remote. Moreover, the inefficiency of medical treatment in 
controlling the progress of the disease, is also an unfavorable 
omen. 

Morbid Anatomy and Pathology.— Although a number 
of the older medical authors have recorded undoubted cases 
of thrombosis, Virchow,* in 1816, was the first to give a full 
and satisfactory explanation of its nature. Since then, many 
cases of cerebral thrombosis, both arterial and venous, have 
been met with, fully confirming Virchow's observations, and 
leaving no room for doubt as to the pathology of the affection. 

Many of these cases are due to atheromatous degeneration 
of the cerebral arteries, of which the following, which recently 
occurred in my practice, is a good illustration. The patient 



* Neue Notizen, Heft xsxvii. 



114 INTRACRANIAL DISEASES. 

was a man seventy-two years of age. For years he had ex- 
hibited symptoms of atheroma, and of fatty degeneration of 
the heart. The radial and temporal arteries were rigid from 
atheromatous degeneration; and when he came under my 
care, about four months previous to his death, there was evi- 
dent disease of the aortic valves. The patient had already had 
two attacks of right-sided paresis, accompanied with aphasia; 
and shortly after I saw him he had another, which came on 
suddenly, and left him unconscious for a period of nearly 
three hours. He, however, slowly rallied again, but never 
fully recovered his speech, nor the use of his right extremities. 
About six weeks after this he had a fourth attack which 
proved fatal, dying in a comatose condition some forty-eight 
hours after the stroke. TJie post-mortem examination showed 
centres of softening in the cortex of the left middle lobe of the 
brain, which were clearly traceable to thrombi blocking several 
of the branches of the left middle cerebral artery, the walls of 
which were all affected with atheromatous degeneration. The 
other cerebral arteries, as well as the aorta and the aortic 
valves, were atheromatous, while the chord se tendinese and 
muscular structure of the heart had undergone fatty and calca- 
reous degeneration. 

A still more remarkable case of arterial cerebral thrombosis 
has been described by Heubner,* in which syphilitic thrombi 
were found closing the right anterior and left middle cerebral, 
the left vertebral, and the basilar arteries. 

In consequence of the diseased condition of the blood-vessel, 
the internal coat becomes roughened — a circumstance which 
favors the deposition of fibrine at that point. The primary 
layer of the thrombus, thus formed, becomes gradually thick- 
ened by fresh accretions, until finally it fills the whole calibre 
of the vessel and completely obstructs it. 

The clot which closes the vessel is, in the beginning, nothing 
but coagulated blood; but as the elements of which it is com- 
posed are deposited gradually, the red corpuscles are washed 
away by the current of blood which continues to flow through 

* Die Luetische Erkrankung der Hirnarterein, 1874. 



THROMBOSIS OF CEREBRAL VESSELS. 115 

the vessel during the process of formation, so that the thrombus 
may be of every shade of color, from a white to a brown. For 
the same reason, the lower layers of the clot are usually of 
greater consistency than those nearer the centre of the vessel. 
and consist almost entirely of fibrine. 

TVnile the artery is undergoing occlusion, the part of the 
brain to which it is distributed is more or less anaemic; but 
as soon as it becomes entirely closed, the anaemic parts change 
to a pink or reddish color, which is known as red softening. 
This state is probably one of passive hyperaemia, combined 
with (edematous swelling and haemorrhage; and unless the 
collateral circulation is speedily and adequately established, 
neero-biotic or yellow softening quickly supervenes. 

Treatment. — The treatment of this affection resolves itself 
chiefly into (1) the removal, as far as possible, of all debilita- 
ting causes and conditions; (2) aiding the general circulation, 
when defective, by both local and constitutional means: and 
(3 1 the administration of such medicines as the symptoms 
may, from time to time, indicate — remedies which have already 
been given under the heads of cerebral anaemia, apoplexy and 
haemorrhage (q. v.). After the collateral circulation has become 
established, electricity will often be found to be a useful aux- 
iliary in restoring the strength of the patient, and especially 
in overcoming the muscular paresis or paralysis still existing. 



116 INTRACRANIAL DISEASES. 



CHAPTER VI. 

EMBOLISM OF CEREBRAL ARTERIES. 

By cerebral embolism is meant the sudden obliteration of one 
or more cerebral arteries or arterial capillaries, by small clots 
carried into them from distant parts of the body. 

Symptoms. — Cerebral embolism, unlike cerebral thrombo- 
sis, has no precursory symptoms, but the patient is seized with- 
out premonition with symptoms of apoplexy, such as sudden 
loss of consciousness and paralysis. These s} T mptoms, how- 
ever, are generally less pronounced than in cerebral haemor- 
rhage, there being in many cases no coma, but merely confu- 
sion of mind, with sudden paralysis of one or more sets of 
muscles on the side opposite the lesion. There are generally 
no symptoms of compression, though there may be epiliptiform 
convulsions. The pulse is usually small and weak, and the 
temperature is somewhat depressed. The symptoms, however, 
vary in different cases. Thus, there may be no paralysis 
whatever, or it may be limited to a single part, as the arm, the 
leg, the face, or the tongue. The faculty of language is generally 
either lost or greatly impaired ; and sometimes there are ocular 
troubles, such as amaurosis, ptosis, or strabismus. There may 
or may not be headache, vertigo, vomiting, dilated or con- 
tracted pupils, and the other signs usually met with in cere- 
bral haemorrhage, the presence or absence of these symptoms 
depending upon the artery affected. Thus, if the embolus 
blocks the left middle cerebral artery, which is its usual site, 
we may have all the signs of corpus striatum haemorrhage, or 
simply hemiplegia with aphasia. Similar effects will be pro- 
duced by blocking of the right middle cerebral artery, except 
that there will be no aphasia. Obliteration of the basilar ar- 



EMBOLISM OF CEREBRAL ARTERIES. 117 

tery by an embolus causes vomiting ; whilst plugging of the 
ophthalmic artery produces sudden amaurosis. The ophthal- 
mic artery and its branches may be gorged with blood from 
embolism of the middle cerebral artery, and then the optic 
papilla will appear red, and the vessels of the retina, enlarged 
and congested. 

Causes. — Acute and chronic endocarditis are the most 
common causes of cerebral embolism. The emboli, which con- 
sist of clots of blood, fibrine, atheromatous debris, or prolife- 
rated connective tissue, are detached from their several seats 
on the valves of the heart and other parts of the endocardium, 
the lining membrane of the aorta, or from a thrombus formed 
in the pulmonary vein, and, entering the circulation, are swept 
onward through the carotid or vertebral arteries into a cere- 
bral artery — generally the left middle cerebral — where they 
become impacted. Other large arteries are sometimes ob- 
structed in this manner, as the internal carotid, the vertebral, 
the anterior cerebral, and the basilar. 

Instead of a stoppage of one of the main cerebral arteries by 
a comparatively large mass, numerous small emboli may form 
from a quantity of fibrinous debris entering the circulation 
from an aneurismal sac, a pulmonary abscess, or a heart-clot. 
An interesting case of this kind occurred under my care, in 
Brown General Hospital, in 1864. Oscar M. Root, of Co. B, 
107th N. Y. Vol., entered the hospital for gun-shot wound of 
the hand. After convalescence, he continued weak and unfit 
for duty, and so was allowed to remain in the hospital. One 
pleasant day in September I gave him a pass to go outside the 
hospital grounds, where he remained three or four hours, 
quietly walking about. On returning, about 5 p.m., he sud- 
denly became unconscious, and was found to be paralyzed on 
the right side of the body. The next day consciousness re- 
turned, but he was unable to speak intelligently. Two days 
afterwards, at midnight, he suddenly died. A post-mortem 
examination showed a large, white heart-clot filling the left 
ventricle, and no less than six small emboli blocking the 
branches of the left middle cerebral artery. There was no 
organic disease of the heart, though the ventricular walls ap- 
peared somewhat thin and flabby. 



118 INTRACRANIAL DISEASES. 

Diagnosis. — When the symptoms of apoplexy are present, 
it may not be possible to distinguish the disease with certainty 
from cerebral haemorrhage; but in many cases there is only 
sudden paralysis without loss of consciousness. Eight hemi- 
plegia with aphasia indicates, as we have seen, occlusion of 
the left middle cerebral artery; whilst embolism of the right 
middle cerebral produces left hemiplegia without aphasia. We 
have also seen that plugging of the ophthalmic artery gives 
rise to sudden amaurosis; whilst the sudden blocking of the 
basilar artery causes vomiting. These are diagnostic points 
of great value when other symptoms are found to correspond. 
When the symptoms of paralysis vanish suddenly, we may be 
sure the stroke was not caused by cerebral haemorrhage; and 
if recovery takes place within two or three days after the 
attack, it can only be referred to an embolus. Moreover, the 
disease occurs without reference to age; there are no premon- 
itory symptoms; the paralysis, in the great majority of cases, 
is on the right side, and is usually combined with aphasia; 
finally, the disease is almost always associated with organic 
disease of the heart. 

Prognosis. — The tendency to softening of the brain is so 
great in every case of cerebral embolism, as to render the 
prognosis exceedingly grave. There can, of course, be no 
safety for the patient until the collateral circulation is fully 
established; still, if three or four days pass without any ag- 
gravation of the symptoms, and especially if they become 
gradually ameliorated, there will be some hope of a favorable 
issue. The degree of paralysis depends upon the extent of 
the lesion, and when this is considerable, death may take 
place within a few hours, but it is not always sudden, and is 
often preceded by pneumonia. In cases where the collateral 
circulation is quickly, but not perfectly restored, there is a 
corresponding improvement in the paralytic symptoms. Thus, 
the limbs may regain a certain degree of voluntary power, 
while the faculty of speech and the mental functions may re- 
main more or less impaired. 

Morbid Anatomy and Pathology. — Since the year 1847, 



EMBOLISM OF CEREBRAL ARTERIES. 119 

when Virchow* first described the manner in which the so- 
called " vegetations," or fibrinous deposits, are detached from 
the valves of the heart and transported to distant parts of the 
body, his observations and conclusions have been confirmed 
by many competent observers, especially by Cohnheim and 
Schutzenberger,f who have shown that the cerebral blood- 
vessels may be plugged by fibrinous concretions derived from 
the heart or large vessels; that this occlusion causes anaemia 
of those portions of the brain to which the affected artery is 
distributed; that in most cases partial or complete hemiplegia 
is the immediate consequence of the lesion; and that if the 
obstruction is not speedily overcome, softening of the brain is 
sure to result. 

The reason that the left middle cerebral artery is most fre- 
quently obstructed by emboli is, that the left carotid — arising 
as it does from the arch of the aorta more nearly in a line 
with the current of blood from the heart, than either the in- 
nominate or the left subclavian — receives the clot, which, after 
passing through the internal carotid, is swept with the more 
direct current into the middle cerebral artery. More than 
three-fourths of all the cases of cerebral embolism on record 
occurred in the left hemisphere, and a still larger proportion 
of these implicated the left middle cerebral artery. 

For obvious reasons, the portions of the brain behind the 
clot are more or less congested, while those to which the oc- 
cluded vessel is distributed are pale and anaemic. An im- 
portant fact in the pathology of embolism is, that the artery 
itself is not diseased. If examined during the first stage, or 
previous to the setting in of cerebral softening, those parts of 
the brain supplied by the obliterated vessel will be found bor- 
dered by a zone of congested tissue, with perhaps a number of 
small extravasations of blood. The changes which take place 
subsequently belong to cerebral softening (q. v.). 

Treatment. — The most that can be done in these cases, in 
the way of treatment, is, to favor the establishment of the 

* Archiv. fur Pathol. Anatomie, I, 272. 
f Gaz. des Hop., 80, 1857. 



120 INTRACRANIAL DISEASES. 

collateral circulation by lowering or raising the head, accord- 
ing as the cerebral circulation is more or less embarrassed; by 
promoting the general circulation by friction, and wrapping 
the body and limbs in warm blankets, in case the patient is 
somnolent and the bodily temperature much reduced ; and by 
the administration of such remedies as are best calculated to 
equalize the circulation and sustain the powers of the system; 
all of which have been fully considered under the heads of 
apoplexy and cerebral haemorrhage (q. v.). 



CEREBRAL SOFTENING. 121 



CHAPTER VII. 

CEREBRAL SOFTENING. 

Softening of the brain usually depends upon embolism 
or thrombosis of certain cerebral blood-vessels, especially of 
the middle cerebral artery. The disease was formerly re- 
garded as an inflammatory affection, whereas it is now known 
to result, in most cases, from disturbances in the nutrition of 
the parts supplied by certain cerebral arteries, the plugging of 
which, by depriving them of nutritive material, eventually 
produces necro-biotic softening. 

Symptoms. — The symptoms vary according as they are 
produced by a thrombus or an embolus. When caused by a 
thrombus, the disease is never so sudden in its invasion as 
when produced by an embolus; neither is it attended by the 
shock to the brain which usually accompanies the sudden 
entry of a foreign body, such as is met with in cerebral haem- 
orrhage and embolism. In whichever way produced, however, 
the symptoms peculiar to those diseases are the ones which 
first present themselves. Thus, we may have the premonitory 
symptoms of thrombosis, such as headache, vertigo, loss of 
memory, difficulties of speech, numbness and creeping chills 
in one side of the body, various ocular troubles, staggering 
gait, incontinence of urine, and other symptoms indicating 
the approach of paralysis; and finally, perhaps, hemiplegia, 
which may occur gradually or suddenly, according as the 
affected vessel is large or small, or according as it affects the 
cortical or basal sphere of nutrition. When, as in many cases 
of embolism, the initial symptoms are those of apoplexy, they 
are similar to those produced by cerebral hsemorrhage, being 
attended in some instances by coma, dilated or contracted 



122 INTRACRANIAL DISEASES. 

pupils, stertor, vomiting, convulsions, and paralysis, as de- 
scribed under that bead. These apoplectic symptoms may 
vanish more or less suddenly, or they may continue with little 
or no remission until the death of the patient, which may 
occur within a few hours after the stroke. 

The first stage in the process of softening is that of simple 
anaemia, and probably lasts only one or two days. If the 
collateral circulation is not fully established, we next have 
one of two conditions, namely, the appearance known as red 
softening, or the condition called yellow or white softening. The 
first is due to hypersemia, with cedematous swelling and haem- 
orrhage, and the latter to the subsequent changes in the af- 
fected tissues, or else to simple necro-biosis of the parts, or 
what is called primary yellow softening, in which the character- 
istic degeneration occurs without any previous hypersemia 
and haemorrhage. 

In cerebral softening, the variations of temperature are more 
frequent, but much less marked, than in cerebral haemorrhage. 
Thus, in many cases, but not in all, the temperature suddenly 
rises soon after the attack to 102°-104° F., and then falls again 
to about the normal average. Sometimes it remains stationary 
at this point for a day or two, or undergoes morning or even- 
ing fluctuations, oscillating back and forth with marked irreg- 
ularity ; but as the softening process advances, the tempera- 
ture gradually begins to rise, and finally reaches a maximum 
of 103° or 104°F., which is much less than that of cerebral 
haemorrhage. 

The next stage, or that of yellow softening, does not usually 
set in until about the tenth day, though it may occur earlier, 
some cases being much more rapid in their progress than 
others. The mental symptoms now become more prominent. 
Delusions and hallucinations occasionally take possession of 
the patient's mind, and sometimes he is delirious, but these 
symptoms are generally of short duration. He is particularly 
apt to be what is called "notional," indicating weakness of 
mind. The mental debility also shows itself in other ways. 
Thus, although unable to execute any complicated intellectual 
operation, or even to concentrate his attention upon any partic- 



CEREBRAL SOFTENING. 123 

ular matter, he ma} 7 nevertheless deem himself fully capable 
of managing his business affairs, and that, too, notwithstanding 
the continuance of motor paralysis and the loss of sensibility 
on one side of the body. As a general rule, however, the mem- 
ory is so much impaired, that if the patient attempts anything 
of the kind, he will make frequent, and often ludicrous mis- 
takes, such as charging himself with articles he has sold, or 
imagines he has sold, to others, and vice versa. It is no un- 
common thing for such patients to forget the names of the 
places where they reside, and even to forget their own names. 
At the same time, it is equally true that softening may occur 
without the patient exhibiting any signs of imbecility; or, 
what is more common, there may be a general loss of intelli- 
gence, and yet some of the mental faculties, such as the will, 
may be greatly increased in power. 

Headache is a very common and persistent symptom of soft- 
ening of the brain ; is usually seated in the forehead ; and is 
generally of a dull, gnawing character. Other troublesome 
head symptoms, such as a sense of constriction, vertigo, weight 
and fulness, are generally present. Drowsiness, also, is a 
prominent feature in these cases, especially in the later stages 
of the disease. 

But the most marked phenomena are those connected with 
the functions of speech and motion. The former is almost 
always more or less affected, either in the form of aphasia, or 
from paralysis of the muscles concerned in articulation. 
AVhen caused by cerebral embolism or haemorrhage, the defect 
is apt to be of an amnesic character, words being either mis- 
placed, or used in a wrong sense ; but when thrombosis or 
capillary obstruction is the cause, the trouble is generally of a 
paralytic nature. Owing to paresis of the muscles of articula- 
tion, many patients omit the last letter or syllable of all but 
the shortest words, both in reading and speaking. Thus, a 
patient of mine called a " Manual of Materia Medica," " Manu 
of Mater Medic." The same patient when asked his name, 
replied, " Samu Wils." This clipping of words is sometimes 
one of the earliest manifestations of the disease. 

As a general rule, however, the first evidence of paresis, in 



124 INTRACRANIAL DISEASES. 

softening of the brain, is manifested in the lower extremity. 
Sometimes the patient stumbles, or the leg suddenly gives 
way at the knee. In other cases, the muscles of the hand and 
arm are first affected. The patient's grasp is weakened, so 
that he frequently drops what he is holding, and if tested by 
the dynamometer, it will be found to be considerably less than 
normal. 

In these cases of chronic softening, the paralysis generally 
goes on from bad to worse, with perhaps occasional intervals 
of improvement, until complete hemiplegia is produced, and 
all muscular power is lost. In cases attended with apparent 
amendment, the patient's friends are very liable to be de- 
ceived with the vain hope that he is recovering, especially if 
the mental condition is also ameliorated ; but the physician 
should not allow himself to be deceived, as these cases are 
almost certain, sooner or later, to terminate fatally. So that, 
whether acute or chronic, the disease eventually is generally 
marked by the symptoms of aphasia, paralysis, coma, convul- 
sions, and death. 

The duration of the disease varies from a few days to several 
years. If, with Hammond and others, we limit the necro- 
biotic process to the stage of yellow or white softening, then 
the range is from ten or twelve days to about three years. 
Some cases, however, terminate by apoplexy in the course of 
three or four days, while others are protracted to as many 
years. The former are generally due to embolism, and the 
latter to thrombosis, of cerebral vessels. 

The symptoms above described are those which belong to 
softening of the cortical substance, the optic thalamus, or the 
corpus striatum. But when the necro-biosis is seated in the 
pons Varolii, and limited to it, there is little or no intellectual 
derangement, but the symptoms are such as we would natu- 
rally refer to that ganglion, such as dyspnoea, cardiac disturb- 
ances, nausea, vomiting, difficulty of swallowing, glosso-labio- 
laryngeal paralysis,* etc., according as the lesion involves one 
or more of the nerves springing from that part of the brain. 

* See Nervous Diseases, p. 168. 



CEREBRAL SOFTENING. 125 

Softening of the cerebellum cannot be distinguished clinically 
from other structural lesions, such as haemorrhage, tumor, or 
abscess, though the symptoms peculiar to diseases of this part, 
taken in connection with the history of the case, may furnish 
sufficient data on which to base a probable opinion. 

Causes. — We have already considered the chief points in the 
etiology of cerebral softening, under the heads of cerebral em- 
bolism and thrombosis (q. v.). Other agencies, however, are re- 
garded as influencing its occurrence, especially age; for al- 
though the disease has been met with at every period of life, 
it is chiefly a disease of old age. Hammond, who claims to 
have seen forty-five cases of cerebral softening which were not 
the result either of haemorrhage, embolism, or thrombosis, says 
that eleven of them were clearly the result of intense and long- 
continued intellectual exertion. Kostan mentions, among other 
causes, blows upon the head, the excessive use of alcoholic 
liquors, and exposure to the action of severe cold, to the rays 
of the sun, or to intense heat. It is probable, indeed, that any 
cause capable of exciting cerebral inflammation, may occasion- 
ally act either as an exciting or a predisposing cause of the 
disease. 

Diagnosis. — Softening of the brain, unless preceded by the 
symptoms of haemorrhage, embolism, or thrombosis, is liable 
to be mistaken for chronic meningitis, meningeal haemorrhage, 
and cerebral tumors. In chronic meningitis, the headache is 
usually more circumscribed, the paralysis more limited, and 
the spasms of the limbs more frequent; while there is an ab- 
sence, in most cases, not only of well-marked febrile symptoms, 
but of that progessive intellectual impairment which charac- 
terizes most cases of necro-biosis. Hsematoma of the dura 
mater may generally be distinguished by the early occurrence 
of coma. Cerebral tumors are characterized by intense pain 
and convulsions, the intellect and speech remaining, as a 
general rule, unaffected. In most cases, also, the history of 
the case will aid in the diagnosis. 

Prognosis. — The prognosis is exceedingly grave, though 
not altogether hopeless. If, as stated by Hammond, the pa- 
tient be young, of good constitution, and of temperate habits; 



126 INTRACRANIAL DISEASES. 

if the centre of softening be small, and not involving the more 
important parts of the brain, there is some encouragement to 
expect a favorable termination. There is no doubt that partial 
cerebral anaemia may occur from embolism of cerebral vessels, 
and yet, owing to the prompt establishment of the collateral 
circulation, never advance to the stage of yellow softening; 
and, on the other hand, the affected tissue may degenerate into 
what is called white softening, the history of which is decidedly 
chronic. But that the necro-biotic process, when once set up, 
can be effectually arrested, or that the paralysis and other 
consequences resulting from it can be permanently overcome, 
is not only highly improbable in itself, but is unsupported by 
any clinical evidence. 

Morbid Anatomy and Pathology. — We are chiefly in- 
debted to the investigations of Virchow, Heubner, Soulier and 
Cohnheim for our present knowledge of the necro-biotic pro- 
cess known as softening of the brain. When the obstruction 
in the cerebral vessels takes place on the far side of the circle 
of Willis, necro-biosis is quickly established, because there is 
no free vascular connection by which a collateral circulation 
can be speedily effected. Hence, the parts supplied by the 
vessel at once become anaemic, and, nutrition being cut off, 
soon undergo one or the other of the following changes: 

In the first place, hyperemia, with ©edematous swelling and 
haemorrhage, may be the speedy result. This is the condition 
known as red softening — a condition long held, both by the 
French and English schools, as being of inflammatory origin. 
In this state, the cerebral mass appears increased, whilst its 
consistency is diminished. The capillary haemorrhage is so 
great as to change the color of the parts to a bright pink, and 
even to a deep red ; but the color gradually fades, until within 
a few weeks it presents the appearance of yellow softening. 

In red softening the color, as shown by the microscope, is 
due entirely to the extravasation of red corpuscles. At a later 
period the nervous elements undergo degeneration. The nu- 
clei of the neuroglia and of the connective tissue of the perivas- 
cular lymphatic spaces, as well as of the muscular coat of the 
blood-vessels, and also the cells of both the cerebral substance 



CEREBRAL SOFTENING. 127 

and the capillary vessels, are all metamorphosed into granular 
globules ; and finally nothing remains but fatty detritus mixed 
with crystals of haematin. 

Now, the explanation of this process is as follows : When an 
isolated terminal artery is obstructed, the blood flows backward 
from the proximal portion of the artery, which is still pervious, 
into the corresponding vein, producing hyperaemia and haemor- 
rhage by transudation of the red corpuscles from the entire 
vascular sphere of the obstructed vessel. 

In case the patient survives a sufficient length of time, white 
softening is produced, the cerebral matter changing into a milk- 
like emulsion, part of which eventually becomes absorbed, 
leaving in some cases a cyst partially filled with liquid, re- 
sembling the cysts found after ordinary attacks of cerebral 
haemorrhage. 

But if no hyperaemia and haemorrhage occur, then we have 
what is called primary yellow softening or simple necro-biosis, 
the parts immediately undergoing fatty degeneration, without 
the previous changes above mentioned. This result occurs, 
according to Cohnheim, in those cases where the blood coagu- 
lates so quickly in the sphere of the obliterated vessel, as to 
prevent any reflux of blood through the corresponding vein — 
an event which is found to occur chiefly where the propulsive 
power of the heart is perceptibly diminished. 

Treatment. — It is evident from what has just been said, that 
the only chance for the patient lies in the early adoption and 
steady use of supporting measures, and that any treatment cal- 
culated to lower the tone of the system, no matter what it may 
be, must have a prejudicial effect. At the same time, it is 
equally evident that, as the symptoms vary according to the 
special cause that produces them, so the treatment must in an 
especial manner be directed against the latter, as affording the 
only chance of curing, or even of ameliorating, the condition 
of the patient. 

As embolism and thrombosis are the two principal causes of 
the disease, the reader is referred to those heads for such treat- 
ment as relates especially thereto. We may also add, that all 
intellectual exertion, and every form of mental and bodily ex- 
citement, should be avoided. If the general circulation is 



128 INTRACRANIAL DISEASES. 

much embarrassed, the patient should be kept in a quiet, re- 
cumbent position, while the body and extremities should be 
kept warm by artificial heat or by additional clothing. 

General Indications. — When caused by arterial obstruction, Abro- 
tanum, Anacard., Arsen., Digit., Xux yom., Phos., Phos. ac, 
Pier, ac, Zinc phosphide, Zincum. 

When recent, or due to inflammatory action, Bell., Gels., Glon., 
Merc, Xux vom., Plumb. 

When there is active hypersemia, Aeon., Bell., Bry., Glon., Xux 
vom. 

Where there is passive congestion, Gels., Opium. 

For headache, Aeon., Bell., Bryon., China, Gels., Glon., Igna., 
Xux vom., Phos. ac, Sulph. 

For vertigo, Arm, Bell., Chin., Con., Digt., Iod., Lack., Xux 
vom., Puis., Sulph. 

For insomnia, Cact., Cham., CofT., Gels., Hyosc, Xux vom. 

For drowsiness, Bell., Digt., Opium, Phosp. ac, Zincum. 

For loss of memory, Alum., Amm. c, Anac, Bell., Bovis., Cocc, 
Hyosc, Xat. m., Olean., Phosp. ac, Sulph. 

For aphasia, Bell., Canst., Colch., Conium, Glonoin, Kali 
brom., Lycop., Oleand., Stram. 

For imbecility, Ambra., Arm, Selen., Sepia. 

For convulsions, Bell., Calc c, Cupr., Xux vom., Strych. 

For local paralysis, Aeon., Bell., Caust., Gels., Igna. 

For general paralysis, Cocc, Conium, Phosp., Phus. 

For hemiplegia, Arnica, Baryta c, Cocc, Xux vom., Strych. 

Special Indications. — Aconite. — Headache, especially when 
caused by active cerebral hypersemia; also for well-marked 
febrile symptoms, or when the bodily temperature is too high, 
especially at the beginning of the disease; local paralysis. 

Belladonna. — When recent, or due to inflammatory action, 
especially if there is a fixed headache, vertigo, drowsiness, or 
loss of memory; absent-minded or forgetful; local paralysis; 
convulsions. 

Digitalis. — Softening of the brain arising from arterial ob- 
struction, and attended with vertigo, or cardiac weakness. 

Gelsemium. — Recent inflammatory cases, or when there is 
headache from passive congestion ; ocular troubles. 



CEREBRAL SOFTENING. 129 

Nux vomica. — Softening of the brain arising from active con- 
gestion, cerebral inflammation, or arterial obstruction; head- 
ache; vertigo; sleeplessness; convulsions; hemiplegia. 

Natrum mur. — Aphasic symptoms; making mistakes in 
writing; talking awkwardly, or in an absent-minded and dis- 
tracted manner, saying things not intended. 

Lycopodium. — Forgetful; omits letters and words in writing; 
uses wrong words to express his meaning; confusion of mind, 
especially about common things. 

Phosphoric acid. — Cerebral softening attended with severe 
headache or drowsiness, with loss of memory; general paralysis. 

Phosphide of Zinc. — Softening of the brain from vascular 
obstruction, especially when accompanied with severe head- 
ache, dizziness, insomnia, loss of memory, or drowsiness; car- 
diac weakness, with palpitation. 

Strychnia. — Cerebral softening from arterial obstruction, es- 
pecially when accompanied by general paralysis, or hemi- 
plegia, or when Nux vomica is inefficient. 



130 INTRACRANIAL DISEASES. 



CHAPTER VIII. 

ENCEPHALITIS. 

Encephalitis, or, as it is sometimes called, cerehritis, is a 
partial inflammation of the substance of the brain ; the dis- 
ease being confined to certain foci, or centres. General inflam- 
mation of the brain seldom or never occurs without involving 
the cerebral membranes, and it is therefore described under 
the head of meningitis (q. v.). 

Encephalitis is not only limited to comparatively small por- 
tions of the cerebral tissue, but is usually of a subacute or 
chronic character. It is, however, sometimes acute, especially 
if the inflammation involves a considerable portion of the cere- 
bral substance, in which case the inflammation passes rapidly 
through its several stages, and may soon terminate in death. 
Even when the disease is limited to a very small portion of 
the brain, it may prove speedily fatal, owing to the particular 
part affected ; as, for example, the corpora pyramidalia of the 
medulla oblongata, or the parts contiguous to the cerebral 
membranes. 

Symptoms. — Although encephalitis is generally marked at 
different stages of its progress with more or less irregularity of 
function, delirium, and spasmodic action, the symptoms vary 
greatly in different cases, and are rarely sufficiently character- 
istic to entitle them to be regarded as pathognomonic. Thus, 
the disease sometimes runs its entire course without giving rise 
to any well-marked cerebral symptoms. In other cases, it be- 
gins in a very slow and insidious manner, and it is not, per- 
haps, until after the disease has made considerable progress 
that the diagnosis becomes at all clear. Again, it may set in 
suddenly, with s}^mptoms of apoplexy, and afterwards run a 
very protracted course ; or, as occasionally happens, the initial 



ENCEPHALITIS. 131 

symptoms may be of a high inflammatory character, in 
which case the cerebral membranes are apt to be more or less 
involved. 

In most cases the patient is attacked with a dull, but some- 
times severe, deep-seated pain in the head, commonly of a con- 
tinuous, but occasionally of a paroxysmal character, which 
frequently precedes all other s}^mptoms. Afterwards, and 
sometimes from the very commencement, other premonitory 
symptoms are experienced, such as vertigo, dimness of vision, 
buzzing in the ears, disposition to faint, nausea, loss of appe- 
tite, hesitancy of speech, wandering pains in the limbs, sensa- 
tion of numbuess or tingling in various parts of the body, with 
heaviness and cramps in the extremities, and an unsteadiness 
of gait, betokening the approach of paralysis. 

These symptoms, however, are all common to other cerebral 
diseases, and although the general health is now more or less 
impaired, the ordinary absence of fever, and of any derange- 
ment of the intellect, prevents, as a general rule, all apprehen- 
sions of impending danger, until at last the patient is suddenly 
seized with stupor, insensibility, and paralysis. From this 
condition he may so far recover as to exhibit some signs of in- 
telligence ; but some degree of drowsiness, apathy, and mental 
weakness, as well as loss or impairment of the special senses, 
remains. As the disease advances, the flexor muscles of the 
paralyzed limbs become rigidly contracted. This condition of 
rigidity, or tonic spasm, is supposed to indicate the process of 
softening of the affected tissues. 

If the patient survives this stage of the disease, the rigidity 
of the paralyzed muscles gradually gives way, and is suc- 
ceeded by complete paralysis. Exacerbations and remissions 
frequently occur, but sooner or later the patient sinks into a 
state of profound coma, from which the system never rallies, 
and death at last closes the scene. This is a brief outline of 
the most common form of the disease; but, as before stated, 
there is no fixed type to the malady, nor any regular order of 
succession in the symptoms. 

In almost every case the mental faculties are more or less 
impaired. As a general rule, symptoms of depression show 
themselves from the very beginning. The patient is drowsy, 



132 INTRACRANIAL DISEASES. 

indifferent, forgetful, thinks slowly, hesitates in his speech, 
and is easily confused. He is seldom attacked by mania, but 
is apt to be somewhat delirious at times. At the close he gen- 
erally sinks into a state of dementia, followed by coma. 

The nerves of special sensibility are generally affected, es- 
pecially those of sight and hearing. Hyperesthesia of the 
retina is not uncommon ; and there is generally more or less 
ciliary neuralgia, accompanied with suffusion of the conjunc- 
tiva, and a contracted state of the pupils. The hearing in 
most cases is very acute at first, and accompanied by tinnitus 
aurium. As the disease advances, however, these two senses 
generally become more and more impaired, and are finally 
lost. 

Common sensibility suffers in like manner; at first from 
hyperesthesia, and afterwards from anaesthesia. Thus, we 
have pains in various parts of the body and limbs, often ac- 
companied by cramps, or we may have formication and numb- 
ness. Headache, though generally present from the begin- 
ning, is not usually very severe, and when it is, it shows that 
the cerebral membranes are more or less affected. 

Fever is seldom a prominent symptom unless the mem- 
branes are implicated, or the disease is complicated by pyaemia, 
otitis, or some other disturbing cause. The temperature rises 
but little above the natural standard, rarely exceeding 102° F. 
The pulse, which at first is generally somewhat accelerated, 
rising in some instances even as high as 120, becomes retarded 
as the disease advances, falling occasionally as low as 40 beats 
in the minute. 

The respiration is not usually much affected in the earlier 
stages, but towards the close it becomes irregular and ster- 
torous, and ends frequently in asphyxia. 

The digestive organs are more or less deranged, the appetite 
being deficient, the tongue coated, and the bowels constipated. 
Nausea and vomiting are apt to prove troublesome, especially 
when the cerebellum is implicated. 

The motor function is almost always impaired, there being 
at first increased excitability, followed sooner or later by pa- 
ralysis. Thus, there is tremor of the flexor muscles, twitch- 
ing of the muscles of the face, and clonic or tonic spasms. 



ENCEPHALITIS. 133 

General convulsions may also occur, especially towards the 
close, with or without loss of consciousness. Paralysis may 
take the form of hemiplegia, or it may be confined to a single 
limb. In most cases, however, it takes the form of paresis, 
causing an unsteadiness in the use of the hands, or a tottering 
gait. The ocular muscles are frequently involved; and we 
may have facial palsy, from implication of the portio dura. 
The action of the tongue and other muscles concerned in ar- 
ticulation are always more or less impaired, rendering the 
speech thick, hesitating and indistinct. 

In the aged the disease generally pursues a very chronic 
course. There is headache, dizziness, general weakness, men- 
tal hebetude, disinclination to work, irritability of temper, de- 
pression of spirits, and restlessness, the latter more especially 
at night. The mental faculties are more or less impaired ; and 
the patient suffers from tremor, epileptiform attacks, and in- 
complete paralysis with contraction. At last the system be- 
comes completely broken down, and convulsions, paralysis, 
delirium, coma, and death, make up the subsequent history. 

AVhen encephalitis is complicated with inflammation of the 
meninges, as in cases arising from otitis, or from injury, the 
symptoms are mixed with those of meningitis. The onset in 
these cases may be gradual or sudden, according to the extent 
of the lesion and the particular parts affected. When the mor- 
bid phenomena are rapidly developed, the cerebral disturbance 
is usually very great, being attended with headache, vomiting, 
fever, convulsions, somnolence, and coma. In other cases, 
the disease is often protracted through many months, remis- 
sions or intermissions alternating from time to time with 
exacerbations. 

If the patient survive long enough, the disease generally ter- 
minates in the formation of cerebral abscess, the chief symptoms 
of which are circumscribed and persistent headaches, usually 
accompanied with rigors, and, in many cases, with convulsions. 

Causes. — Encephalitis is generally the result of traumatic 
injuries, such as blows, falls, etc. Hence it is found to occur 
chiefly in adult males, who are more exposed than females to 
this class of accidents. Erysipelas, ozcena, caries, syphilis, 
scarlet fever, glanders, variola, pyaemia, septicaemia, and 



134 INTRACRANIAL DISEASES. 

typhoid fever, may give rise to it by transmitting the morbid 
process to the cerebral tissues. It may also be caused by the 
development of foreign bodies in the brain, such as tumors and 
aneurisms. Among other causes are long-continued and severe 
intellectual exertion, mental anxiety, venereal excesses, expos- 
ure to extreme heat, and especially the inordinate use of alco- 
holic liquors. 

Diagnosis. — Encephalitis is liable to be mistaken in some 
cases for acute meningitis, and in others for cerebral haemor- 
rhage, tumors, or the disease called general paralysis. In acute 
cerebral meningitis, the fever is always much greater than in 
encephalitis; the convulsive movements are also more general, 
the headache is more severe, and the delirium is more constant 
and marked. In cerebral haemorrhage the symptoms, instead 
of becoming more and more pronounced as the disease pro- 
gresses, as in encephalitis, generally become progressively 
ameliorated. The symptoms attending the formation of cere- 
bral abscesses closely resemble those which accompany the 
growth of tumors in the brain ; and the same is true of those 
which characterize the disease known as general paralysis.* 
Encephalitis is generally of shorter duration than general pa- 
ralysis, and is not marked by the "mania de grandeur" peculiar 
to the latter affection ; but our chief reliance in the diagnosis 
must be the history of the case. 

Prognosis. — Idiopathic encephalitis is almost always fatal ; 
the same is also true when the inflammation spreads from 
neighboring parts. When the disease results from injury 
there is some hope of recovery, but not after it has passed the 
stage of red softening. Occasionally, after the brain tissue 
has broken doAvn and an abscess has formed, the pus escapes 
from the cranium through the nose or ear, or through some 
artificial opening; but however promising the first effect of 
the discharge may appear, the amelioration of the symptoms 
is found to result simply from the diminution of pressure, and 
to be of but temporary benefit; the patient gradually passes 
into a state of deep coma, which is soon followed by death. 

Morbid Anatomy and Pathology.— The first change that 

* See Nervous Diseases, p. 173. 



ENCEPHALITIS. 135 

occurs in the affected tissues is that of red softening, there 
being hyperemia and capillary haemorrhage, which renders 
the cerebral matter moister and softer than usual, and gives it 
a reddish appearance. The microscope shows an abundance 
of white corpuscles, disintegrated red corpuscles, and nerve- 
fibres, masses of nuclei, amyloid corpuscles, and pus. The 
arterial capillaries are dilated, and their thickened coats in a 
state of fatty degeneration. 

After a time the blood corpuscles become entirely dissolved, 
forming with the disintegrated cerebral matter a jelly-like 
substance; or else a dirty yellowish matter is left, which 
becomes enclosed in a membranous capsule or cyst. Yellow 
bands of sclerosed connective tissue are found in the grey 
matter of the brain, closely connected with the pia mater, 
which is thickened and opaque. 

The most frequent seat of the inflammatory process is the 
grey matter of the cortex, the corpora striata, the optic thalami, 
and the cerebellum. Although' there may be several centres, 
the inflammation is never widely diffused. The cineritious 
matter is generally first attacked, and afterwards the inflam- 
mation spreads to the white substance. As a consequence, 
cerebral abscesses occur chiefly in the medullary matter. 
When multiple they are generally small, being sometimes not 
larger than a hazel-nut; in general, however, they vary in 
size from that of a cherry to that of a small orange. 

In acute cases the abscess is irregular in shape, and being 
surrounded by no membranous capsule, encroaches more and 
more upon the adjacent cerebral substance, which is in the 
condition of red and grey softening. In this way the pus may 
ultimately reach the surface of the brain, or break through 
into the lateral ventricles; and if, as is generally the case in 
these instances, the disease is due to injury or caries of the 
cranial bones, the pus may eventually escape through the 
nose or ear. 

But when the inflammatory process is more chronic, the 
abscess is generally of an oval form, and contained in a mem- 
branous capsule composed of connective tissue. If large the 
abscess will give rise to symptoms of compression, and if rup- 
tured will prove speedily fatal. 



136 INTRACRANIAL DISEASES. 

Treatment. — The treatment of this disease is similar to 
that recommended for cerebral hyperemia, meningitis, and soft- 
ening (q. v.). The only curative stage, if such there be, is the 
first or congestive period. So long as there is neither heem- 
orrhage nor softening, we may reasonably hope, not only to 
relieve the symptoms, but to cure the inflammation. But 
when suppuration and abscess have occurred, we can only 
hope to palliate the symptoms, prolong life, and render the 
patient's condition more comfortable. 

Kafka claims to have used Glonoin 1st to 2d, successfully, 
for a number of years, in this disease — even when the disorgan- 
izing process was progressing — so long as the symptoms of 
cerebral hyperemia predominated. No doubt Glonoin will 
prove a valuable remedy in the initial and purely hypersemic 
stage of the malady; but it is not likely to prove anything 
more than palliative after the suppurative process has set in. 

Kafka also relates a case in which Arsenicum was used, appar- 
ently with success, even when cerebral softening, with progres- 
sive increase of the morbid phenomena, coexisted side by side 
w r ith the symptoms of cerebral hyperemia ; the remedy having 
been employed after the hypersemic condition had been re- 
lieved by the administration of Glonoin and Belladonna. If, 
as I have elsewhere stated, it be possible for complete recovery 
to take place in encephalitis after disorganization of the cere- 
bral tissues has occurred, I have no doubt Arsenicum will prove 
an efficient remedy, not only because it is capable of producing 
decomposition of organic tissues, but because its pathogenesis, 
as exhibited in the cephalalgia, vertigo, wandering pains, im- 
paired sensibility of the limbs, delirium, coma, lassitude, de- 
bility, trembling, tetanic spasms, and paralysis, presents a per- 
fect picture of cerebritis, and is therefore truly homoeopathic 
to that condition. 

Other remedies, such as Iodine and Plumbum, have been 
recommended in this disease, but chiefly on theoretical grounds, 
there being but little clinical experience in their favor. 

Cannabis indica and Kali bromalum have proved highly 
useful in some cases by lessening the irritability of the nervous 
system. 



CEREBRAL HYPERTROPHY. 137 



CHAPTER IX. 

CEREBRAL HYPERTROPHY. 

By hypertrophy of the brain is meant, not an excessive devel- 
opment of the cerebral substance itself, but an excessive growth 
of the neuroglia, or interstitial connective tissue, whereby the 
bulk of the organ is abnormally increased. The hypertrophy 
is mostly confined to the hemispheres, the pons Varolii, and 
the medulla oblongata; the cerebellum is scarcely ever affected. 

Symptoms. — So long as the skull is yielding — i. e., during 
infancy and childhood — there may be no observable symp- 
toms; no disturbance of motion and sensation, nor even of the 
mental faculties, except such as arises from an undue enlarge- 
ment of the head. At a later period, however, symptoms of 
pressure are likely to manifest themselves, giving rise at first 
to general muscular weakness, especially in the lower extremity. 
As a consequence, the patient's grasp is weak, and he is apt to 
stagger and stumble in his walk. Paralysis and convulsions 
are of rare occurrence, even in a mild form ; but ow T ing to the 
anaemic state of the brain, the convulsions, which, if present, 
are at first partial and of short duration, sometimes develop 
into well-marked epilepsy and eclampsia. 

Sensibility is likewise impaired, though rarely to the extent 
of actual anaesthesia. Headache and vertigo are not uncom- 
mon, and we may also have tinnitus aurium, photophobia, and 
dilated pupils. The mind is generally more or less depressed, 
exhibiting, in some cases, a marked degree of mental torpor 
and vacuity, or even idiocy. Mental excitement, on the other 
hand, is rare ; but owing to incidental circumstances, a con- 
dition of cerebral hypersemia sometimes exists, attended with 
delirium, and occasionally with mania. 



1-1 S DTTRACRAOTAT. DM 

C uses. — Hypertrophy of the brain is sometimes congenital. 
The strumous constitution appears to form a predisposition to 
the disease, as it is frequently developed during infancy and 
early childhood, in connection with rachitis and enlarged lym- 
phatic glands. In adults it is chiefly confined to males, espe- 
cially those addicted to the re use of alcoholic liquors, 
me. -- timmes rem .:;.". ::nmm :n. 

Diagnosis. — In infancy, owing to the enlargement of the 
head, the disease is liable to be mistaken for hydrocephalus. 
The chief difference between them is, that children affected 
with cerebral hypertrophy are mentally brighter and more 
precocious than usual, while in hydrocephalus it is the reverse. 

Prognosis, — In :-::-: rases me iisease r- t::::t^t/' m~ m 
irs ::^-:r:5. I:: mrimen .".:-. m rim - - rakes mare fmm 
pressure caused by cerebral congestion, the result of incidental 
diseases which, under other circumstances, might have a dif- 
remm issue Ir: ;_ :lul:^ trie amentia ami mm-trie rives 

s to apoplectic attacks which often prove speedily fatal. 

Morbid Anatomy and Pathology. — On removing the 
mmmmr m i : renins tie intra mater rm main immediately 
e.m ands to snch a site as to overlap the bones. The convolu- 
tions are flattened, and the fissures hardly discernible. The 
ventricles are also narrowed by compression, and contain 
scarcely any serum. The cerebral tissue is pale, dry and 
anaemic ; the membranes thin and bloodless; and even the 
skmimmes ire trim ami art: rmie i mm messme. A rareim 
examination shows, that while there is no undue amount of 
cerebral matter present, there is an excessive development of 
me nemmm rmlermr :ne main i:.mr.m. ani mm 
elastic than the normal organ. 

Treatment. — The treatment, which is necessarily wholly 
palliative, consists chiefly in improving the general health, 
guarding against exposure to all injurious influences, relt - 
ing cerebral hyperemia when present, and abstaining alto- 
gether from the use of alcoholic liquors. Remedies specially 
mmir: me~~.rm.rs nmirrrm. mm:: emmi imrrm 
the course of the malady, are those usually employed in cere- 
bral anaemia and hyperssmia, convulsions, epilepsy, and paralysis, 
ami metmte met" n;r :e temtrei iiere. 



CEREBRAL ATROPHY. 139 



CHAPTER X. 

CEREBEAL ATROPHY. 

Atrophy op the brain is, properly speaking, a simple 
wasting of the brain tissue, without its undergoing any de- 
generative changes; but, as commonly used, it also includes 
that form of atrophy which is sometimes associated with what 
is known as diffuse cerebral sclerosis. 

Symptoms. — The disease when congenital constitutes the 
various grades of idiocy. Children subject to it are more or 
less idiotic, and suffer from epilepsy and paralysis. The 
symptoms are generally more severe in early life than they 
are at a later period. The mind is weak, and generally more 
or less depraved and revengeful. The special senses, if not 
entirely wanting, as in the deaf, dumb and blind, are usually 
very deficient. There is hemiplegia, generally incomplete, 
with anaesthesia and atrophy of the paralyzed parts, including 
both the muscles and the bones. Hence the limbs are thin, 
short, and often disproportioned to the size of the body; there 
is also a wasting of one side of the face. The deformity is 
often rendered still greater by an hypertrophy of the adij)Ose 
tissue. 

Cerebral atrophy also occurs during adult life; and may be 
either partial or general, stationary or progressive. 

Partial atrophy of the brain is generally due to local lesions, 
such as haemorrhage, softening, and encephalitis. In these 
cases the initial symptoms are usually those of apoplexy, en- 
cephalitis, etc., the motor paralysis being unilateral and more 
or less stationary. In the course of time, however, the atrophy, 
though partial, becomes sufficiently great to cause a gradual 
deterioration, not only of the mental faculties, but of all the 
functions of the nervous system. 



TEACRAXIAL DISEASES. 

ors mostly _ The 

A and progress ith 

_ radual Loss The mind zolarly 

g no mental er. _ 
- ient lan_ 

_ _ 5. In most cases i 

- 

is i and an 

cranial ne: - ;.nd a sJ 

llse rhc last stage resem- 

bles thai : the - _ ral paralysis : the in- 

san _ a victim to lecnhitus liarrhces pul- 

monary liseasc : Ire sy 

Causes. — Partial atrophy ss _ ital, is ; 

result of sti^o lo:-a" disease such as n agf 

- : ; encephalitis tumors, etc In the: 

is confined tc me hemis and may Beet any tissue or 

par: sf it When genera] it is rften associ nic 

alcoholism Bright 1 * liseasc : the kidney shi m ::■ blood poi- 
: ....:._ r some other fc rm of cachexia. 

Diagnosis. — Ihc liagnosis : cerebral atrc 

iple ii complicated with linuse cerebral sclerosis mnsl 
ays be very ancertahi since "It symptoms arc doI 
: :l ... m tc both foi ins but alsc tc >thei iiseases rae- 

ti as are m : i - : mm l scleras 

havT jccorrec ition to the other sn .ere 

t . i kedm contractions and yet no sclerosis c mid 

be detected m post-mortem Examination. 

The symptoms : mbosis and softening : : ben bear a 

striking resemblance tc those :: serebral especj 

Id the sclerosed form bat in the latter disease the c o 

generally met with at an earliei period and they are also 
! const: 

Prognosis. — Pui - complicated the brain, 

whro. a congenital >i isnnd ibtedly incnrable bnt 

when the atrophy is progi sssive there ms y be - m 3 | rospect 
of ameliorating the : ... :: the patient causing an 

absorption . : blood-dots iiminishing pressure from conges- 
arresting ret rding progress : the liseaseby im- 



CEREBRAL ATROPHY. 141 

proving the nutrition of the atrophied cells, and by mitigating 
the severity of the symptoms, especially convulsions and mus- 
cular contractions. At the same time it must be admitted 
that, as a general rule, very little permanent good can be 
effected in these directions in this class of cases. 

Morbid Anatomy and Pathology. — In congenital cases, 
the atrophy is generally limited to one hemisphere, usually 
the left, which is sometimes less than half the size of the right. 
The atrophy involves not only the cerebral ganglia, but ex- 
tends to the corresponding crus, pyramid, and antero-lateral 
column of the cord. The ventricles are widely dilated, and 
contain a considerable amount of serum. The brain substance 
varies greatly in consistence, being sometimes soft, at others 
hard and elastic. 

In partial atrophy, the aplasia is confined more particularly 
to the nerve-cells, though it may affect any of the cerebral tis- 
sues. In these cases the atrophy extends, until it reaches, as 
in the former case, the lateral column of the spinal cord. The 
degenerated tissues are found to contain numerous amylaceous 
and colloid corpuscles and granular cells. 

General cerebral atrophy is symmetrical, and is primarily 
seated in the neuroglia, the nerve-cells becoming affected sec- 
ondarily. The convolutions are shrunken, and in some places 
widely separated. The ventricles, subarachnoid space, and 
meshes of the pia mater, contain a large amount of serum ; the 
blood vessels are abnormally twisted and enlarged ; the mem- 
branes are thickened and hazy; and the cerebral tissues, though 
occasionally soft and moist, are generally hard and elastic. 

Treatment. — The only remedies that I have found to be 
of any very great value in this disease, are Baryta carb., Baryta 
% mur., and Baryta iod. Not only does the symptomatology of 
Baryta correspond closely with that of cerebral atrophy, but 
the clinical evidence in its favor is by no means inconsiderable. 
It has been found to be especially adapted to the physical, men- 
tal and nervous weakness experienced in these cases, and to be 
equally suited to the atrophy of children, the strumous dys- 
crasia associated with it, and the paralysis of old people, espe- 
cially when produced by apoplexy. Other remedies which 



142 INTRACRANIAL DISEASES. 

may sometimes prove useful, are those usually employed in 
cerebral hxmorrhage, encephalitis, hemiplegia, convulsions, and 
epilepsy. 

Electricity, in the form of galvanism, may also be employed 
in these cases with occasional benefit. Both the induced and 
primary currents may be required, the interrupted current 
being the best for the paralysis, and the constant current for 
the relaxation of contractions. Ten ordinary cells will gener- 
ally furnish a current of sufficient intensity, the sponges being 
applied over the mastoid processes every second or third day, 
for a period not exceeding three or four minutes at a time. 

That these measures iD crease the nutrition of the atrophied 
cells, in some cases, there is good reason to believe, since we 
have more than once seen the paralysis lessened, the contrac- 
tions relaxed, the mind improved, the epileptic paroxysms ar- 
rested, and the wasted limbs considerably enlarged and 
strengthened, by their influence. 



PRIMARY MULTIPLE SCLEROSIS. 143 



CHAPTEK XI. 

PRIMAKY MULTIPLE SCLEEOSIS. 

I make use of the term " primary " to distinguish this form 
of cerebral sclerosis, because multiple sclerosis may be limited 
to either the brain or spinal cord, or it may involve both. 
Charcot has shown* that cerebral lesions, locally considered, 
do not all equally tend to produce secondary sclerosis, some 
being almost always followed by descending sclerosis, while 
others never are. To the latter belong, more particularly, 
those lesions which are confined to the substance of the central 
grey masses, namely, the lenticulated and caudated ganglia 
and the optic thalami. The same is true of the grey cortical 
substance of the hemispheres, when very superficial, and, in 
certain cases, even when extensive and profound. We shall 
see hereafter, that in primary multiple sclerosis of the brain, 
the lesion consists of plates or nodules of sclerosed tissue 
scattered throughout the entire substance of the cerebrum. 

Symptoms. — One of the first and most marked symptoms 
of this disease is pain in the head; not a constant, but a sharp, 
electric-like pain or shock. In other cases, the first symptom 
observed is an epileptic paroxysm. Shooting pains, of a simi- 
lar nature to those in the head, are also experienced at times 
in other parts of the body. But the most common disorder of 
sensibility is a peculiar numbness of the extremities of the 
fingers or toes. The sensation, which is generally limited at 
first to one upper or lower extremity, is that of cushions, and 
is only experienced when objects are touched. 

Disorders of motility are next experienced, but as the prog- 

* Localization in Diseases of the Brain, 1878. 



144 INTRACRANIAL DISEASES. 

ress of the disease is generally slow, it is often many months 
before they make their appearance. Of these, the first and 
most characteristic is tremor. This symptom is generally 
gradual in its development, being sometimes confined for 
months to a single muscle of the hand or foot, and afterwards 
involving the extensors and flexors of the entire member or 
limb. The trembling generally begins in one of the limbs, 
and gradually extends to the other limb on the same side, and 
lastly to the head; but sometimes it commences in the head 
and afterwards invades the limbs, unilaterally, one after the 
other. At first, and for a considerable period after the begin- 
ning of the disease, the tremor is to some extent under control 
of the patient's will. Thus, he will sometimes stamp his foot 
upon the ground and arrest the trembling for a few seconds, 
but the respite grows shorter and shorter, and finally ceases 
altogether. The same is true of sleep, which usually has a 
quieting effect at first, but eventually it ceases to afford any 
relief whatever. The tremor is always increased by emo- 
tional excitement, and not unfrequently by the voluntary 
efforts of the patient to arrest it. The trembling is not con- 
fined to the muscles which move the head and limbs, but 
sooner or later involves those of the face. The eyeballs, the 
upper lid, the lips, the lower jaw and the tongue, are the parts 
principally affected. 

Paralysis is the next symptom of importance, and, accord- 
ing to Hammond,* when the sclerosis is limited to the hemi- 
spheres, or begins in them, it always follows the tremor. This 
is doubtless true in the primary form of the affection, which 
we are now considering, and is an important point in the 
differential diagnosis. The same authority also claims, not 
only that the paralysis always succeeds the general appearance 
of tremor in these cases, but that it also follows the course of 
the trembling, no limb ever being paralyzed till it has for 
some time been affected with tremor. This, however, does not 
apply to the muscles of the face, the paralysis of which appears 
to be independent of the tremor. 



Op. cit. 



PRIMARY MULTIPLE SCLEROSIS. 145 

But while paralysis appears to follow the appearance of 
tremor in the limbs, the same does not always seem to be true 
of paresis, which may exist prior to the occurrence of the 
trembling. This is best shown by the dynamograph, the pa- 
tient being unable to maintain continuously an equally strong 
grasp, even for a short period. 

Incoordination of muscular movements is closely connected 
with paresis. It is only by concentrating the volitional power' 
upon the object by means of sight, that the muscles can be 
made to act in harmony, so as to successfully carry out the in- 
tended movement. Thus, I once had a patient affected with 
this disease, who was not able to carry food to his mouth with- 
out steadily looking at it during the performance of the act. 
Dr. Hammond mentions the case of a lady affected with this 
disease, who undertook to help her invalid husband to rise 
from his chair, and as she turned to look at a band of music 
which happened at that instant to pass the door, she involun- 
tarily relaxed her hold, and let him fall to the floor. 

Patients affected with this disease often manifest a great 
degree of haste in their movements, especially in walking. 
Sometimes the gait almost amounts to a trot. This peculiar 
walk doubtless arises from the greater ease with which such 
patients are able in this manner to carry out their intended 
movements and maintain their equilibrium. 

Sensibility is variously affected in these cases. Thus, there 
may be, not only anaesthesia, but more or less hyperesthesia, 
deafness, amblyopia, and, in some cases, complete amaurosis. 

The disease, which is always progressive, may last from a 
few months to eight or ten years, or even longer. Slow as it 
may be in its progress, however, the patient sooner or later 
becomes bedfast, and finally dies, either of decubitus, coma, or 
convulsions. 

Causes. — Age appears to act as a predisposing cause of pri- 
mary multiple sclerosis, as the disease seldom affects } T oung 
people, or those under fifty- years of age. There is some doubt 
whether heredity has anything to do with its origin, though 
Hammond says, that of thirteen cases which have occurred in 
his practice, five had immediate ancestors who suffered from 

10 



146 INTRACRANIAL DISEASES. 

some form of tremor and paralysis. The disease is much more 
common in males than females. Among the exciting causes 
may be mentioned, syphilis, rheumatism, scarlatina, typhoid 
fever, and inordinate mental and physical exercise. 

Diagnosis. — The disease is most liable to be mistaken for 
paralysis agitans ; indeed, it has heretofore been generally in- 
cluded under that head. But functional paralysis agitans, 
which is a very different affection, is more apt to occur before 
than after fifty years of age. Moreover, in the latter disease 
there are no head symptoms, no muscular incoordination, no 
inability to trace a straight line with the dynamograph, no 
muscular anaesthesia, and no abnormal states of sensibility. 
As to the secondary form of multiple sclerosis, it may gener- 
ally be distinguished by the fact that the tremor precedes the 
paralysis, and also by the fact that the trembling is associated 
with voluntary as well as with involuntary muscular move- 
ments. 

Chorea also bears considerable resemblance to this disease, 
but may be distinguished from it, not only by the history of 
the case, but by the facts that it generally occurs in youug 
people, has no head symptoms, nor any actual tremor, but 
simply a more marked degree of incoordination, the disorderly 
movements being more irregular and extensive. 

Prognosis. — The prognosis in this malady is bad, very bad; 
but if seen early and subjected to proper treatment, the dis- 
ease, if not entirely arrested, may often be rendered lighter, 
and the patient's life prolonged and rendered more com- 
fortable. 

Morbid Anatomy. — The general condition of the brain is 
similar to that described under the head of cerebral hyper- 
trophy, though less pronounced. Thus, the convolutions are 
somewhat flattened by pressure, the grey substance is atrophied 
and anaemic, while the membranes are more or less opaque, 
and contain an unusual quantity of serum. 

But the chief morbid condition observable in these cases, 
consists in plates or nodules of indurated matter, found scat- 
tered throughout the tissue of the cerebral hemispheres. These 
masses of hardened tissue vary in size from that of a hazel- 



PRIMARY MULTIPLE SCLEROSIS. 147 

nut to that of a small walnut. Their color is white, or nearly 
so, and their density varies from that of fresh cheese to that 
of cartilage. 

The microscope shows them to consist mainly of the neu- 
roglia, which has undergone hypertrophy at the expense of 
the nervous tissue, the debris of which are also present in the 
form of fibres, free nuclei, and nucleated cells. Amyloid cor- 
puscles are sometimes present, but not always. 

The patches vary greatly in number, being sometimes pres- 
ent in large numbers, while occasionally they are solitary. 
They are not confined to the hemispheres, though that is their 
usual seat; but they are occasionally found at the same time 
in the medulla, the pons, and the cerebellum. When the 
spinal cord is likewise involved, it is no longer a case of pri- 
mary, but of secondary multiple sclerosis. 

Pathology. — That numerous cases of multiple sclerosis have 
been observed in which the lesion was confined to the brain, 
cannot be questioned. Bat whether these cases are really 
different in their nature from those in which the spinal cord 
is also implicated, is not so certain. We know that multiple 
sclerosis is progressive, and we also know that in many cases 
the spinal form is secondary to that of the brain. But it does 
not follow, by any means, that it is always so; nor that the 
primary disease is not, in many cases at least, an independent 
affection. Certain it is, that when confined to the encephalon, 
it gives rise to symptoms sufficiently characteristic to entitle 
it to be regarded as a distinct affection. 

Treatment. — The treatment of this disease does not differ 
essentially from that already given under the head of cerebral 
atrophy (q. v.). In addition, however, to the measures there 
recommended, I would suggest a trial of the following reme- 
dies, some of which I can recommend as useful from actual 
experience: Argentum nitr., Belladonna, Helleborus, Hyoscyamus, 
Stramonium^ Tarantula, and Zincum. 



148 INTRACRANIAL DISEASES. 



CHAPTER XII. 



ATHETOSIS. 



The term athetosis, from atferoc, without fixed position, was 
first used by Dr. Hammond, to designate a comparatively new 
and peculiar nervous disease, the chief characteristics of which 
are, an inability to retain the fingers and toes in any fixed 
position, and by their constant motion. 

Symptoms. — The disease usually sets in with one or more 
epileptic paroxysms, followed in some instances by loss of 
motion, sensation, and speech. As a general rule, however, 
there is no paralysis, but there is always more or less numb- 
ness on the affected side, which is generally the right. The 
intellect is always impaired, the memory enfeebled, and in 
most cases there is cephalalgia and vertigo. There may or 
may not be aphasia; but there is generally more or less tremu- 
lousness of the tongue, even when there is no paralysis. The 
characteristic symptoms, however, are the athetoid movements 
of the fingers and toes, with pains in the spasmodically affected 
muscles, and a tendency to distortion. 

The movements of the affected member, though complex 
and involuntary, are to some extent under the control of the 
patient. Thus, one patient, when told to close his hand, 
seized the wrist with the other hand, and then, by exerting all 
his power, succeeded at last in closing his fingers, but they 
immediately opened again and renewed their movements. 
The movements are not those of simple flexion and extension, 
but complicated and grotesque. They occur both when awake 
and when asleep, and are only temporarily restrained by 
certain positions and by powerful exertions of the will, as 
when held in a vertical position, or when firmly grasped. 
During the continuance of the movements, the muscles of the 
affected limbs are in a state of tonic spasm, causing them to 
appear hard and rigid. The movements, which take place 



ATHETOSIS. 149 

slowly and with great force, are somewhat paroxysmal, being 
worse at one time than at another, but never cease altogether. 
When, by an extreme exertion of the will, the patient succeeds 
for a moment in quieting the movements of the fingers, they 
at once become strongly abducted, and remain so until the 
movements are resumed. 

The contractions increase in severity as the disease pro- 
gresses, and the numbness and pain in proportion to the in- 
crease in the contractions. For half an hour or so after sleep 
there is usually a period of comparative repose, the move- 
ments then being somewhat less severe; but sometimes the 
patient has great difficulty in getting to sleep, in consequence 
of the severity of the pain caused by the tonic contractions. 
The affected limbs become developed to a greater degree than 
the others, owing to the almost continuous action of their 
muscles. 

Causes. — Nothing is positively known as to the cause of 
this singular malady. Dr. Ringer thinks that it is sometimes 
due to embolism of the left middle cerebral artery, as the 
symptoms in some cases appear to correspond with those pro- 
duced by such a lesion. In other cases they resemble those 
of general cerbral atrophy. 

Diagnosis. — The disease is liable to be confounded with 
post-hemiplegic chorea, as has actually been done by Charcot 
and others. In the latter disease, however, the movements 
are quick, irregular, jerky, and variable; while in athetosis 
they are slow, uniform, and systematic. Moreover, athetosis 
is not always preceded by hemiplegia; neither is it always 
confined to one side of the body, MM. Oulmont* and Broussef 
having described cases of double athetosis without liemiplegia. 

Prognosis. — There is little or no hope of ultimate recovery 
in these cases. The prognosis in any particular case will 
largely depend, of course, upon the nature of the cause; and 
as athetosis is in all probability the result of degenerative 
changes in the central ganglia of the brain, the final outcome 
must be bad. 

Morbid Anatomy and Pathology. — The disease appears 

* Etudes Cliniques sur VAthetose, Paris, 1878. 
f Montpellier Medical, t. xxxiv, 1877. 



150 INTRACRANIAL DISEASES. 

to be seated chiefly in, and just external to, the central cerebral 
ganglia — the corpus striatum and optic thalamus. In Dr. Rin- 
ger's case, the whole of the corpus striatum was much damaged, 
involving both the caudated and lenticular nuclei. There was 
not only much atrophy and slight degeneration of the intra- 
ventricular portion, but about one-fifth of the lenticular gan- 
glion was destroyed, as well as a few of the fibres of the inner 
capsule, passing between the nuclei of the corpus striatum. 
The optic thalamus was also atrophied, and a small portion 
of the lower and outer part of this body was completely de- 
stroyed, while a considerable portion of the white matter ex- 
ternal to the thalamus, embracing sensory fibres of the external 
capsule, was also destroyed. In the case reported by M. Lan- 
douzy,* there was found an old centre of softening occupying 
exclusively the lenticular portion of the corpus striatum. In 
a case reported by Dr. Sturges,f the whole of the anterior por- 
tion of the corpus striatum was destroyed. 

Dr. Ringer sums up the pathology of his case — a patient 
who had mitral obstruction with regurgitation — as follows: 
"Dazzling before the eyes, dimness of sight, giddiness preced- 
ing loss of consciousness, and followed by loss of speech and 
sensation, and motion of the right side, point conclusively to 
the left hemisphere of the cerebrum as the seat of the disease. 
The giddiness indicates the mesencephale; the loss of speech, 
the posterior part of the third frontal convolution ; the loss of 
sensation, the thalamus opticus ; and the loss of motion, the 
corpus striatum, as the parts probably affected. As speech 
returned before sensation, and sensation before voluntary mo- 
tion, the main stress of the disease must have fallen on the 
corpus striatum, and in a less degree on the thalamus opticus. 
It is probable, I think, that the cause of the disease in this 
case is an embolon set free from the diseased mitral valves 
blocking the middle cerebral artery." 

Treatment. — The treatment, which should be based upon 
the symptoms, is similar to that given under the heads of 
embolism, softening, epilepsy, hemiplegia, and cerebral atrophy 

(q- 4 ,. 

* Progres Medicate, 1878. 
f Lancet, March, 1879. 



PROGRESSIVE FACIAL ATROPHY. 151 



CHAPTER XIII. 

PROGRESSIVE FACIAL ATROPHY. 

This disease was first described by Parry as early as 1825, 
but did not attract much attention until Lande, who collected 
a considerable number of cases, described the affection under 
the name of progressive laminar aplasia. 

Symptoms. — The first symptom usually noticed in these 
cases is a white or pale spot on one of the cheeks. This spot 
is more or less irregular in outline, and exhibits a tendency to 
spread in one or several directions. At the same time, or 
shortly afterwards, a slight depression is observed in the same 
place, owing to atrophy of the skin and cellular tissue. Sub- 
sequently, the muscles themselves undergo atrophy, thereby 
causing a still greater depression in the cheek. 

As the disease progresses, other points of atrophy make their 
appearance in the vicinity, the wasting process continuing 
until, in some cases, the muscles of the face, the lips, and, in 
some rare instances, even those of the neck, become involved. 
In many cases the tongue is atrophied on the side correspond- 
ing to the facial disease, and when protruded it points towards 
the affected side. The disease sometimes involves the veil and 
pillars of the palate, the uvula, and even the muscles of the 
larynx; nevertheless, the function of deglutition is not im- 
paired, nor is that of phonation often interfered with. 

The affected muscles, which, though weakened, are never 
completely paralyzed, retain their electro-excitability, but are 
sometimes affected by fibrillary contractions. 

Sensibility is not generally disturbed, but neuralgic pains 
are sometimes felt in the vicinity of the parts, especially in the 
fronto-temporal region, and spasmodic movements occasionally 
occur in the muscles of the face or jaws. 



152 INTRACRANIAL DISEASES. 

The nutrition of the skin begins to suffer at an early period 
of the disease, as shown not only by the white spot in the 
trophic centre, but by the discoloration and falling out of the 
hair, the cilia, the supercilia, and the beard, as well as by the 
diminution of the sebaceous secretion on the affected side. 

Causes. — The etiology of progressive facial atrophy is ob- 
scure. Although the disease is generally met with in early or 
adult life, and is more common in females than in males, 
Vulpian attributes its origin in a certain number of cases to 
traumatic violence inflicted on the head and face. In one 
case it is said to have followed an attack of scarlatina. 

Diagnosis. — In its early stages, the disease might, in some 
cases, be mistaken for facial paralysis. The latter, how r ever, 
comes on suddenly, while this is developed very gradually; 
moreover, the electro-excitability of the muscles is always di- 
minished in facial paralysis, which is not the case in this 
disease. 

Progressive muscular atrophy, when seated in the face, is 
not confined to that part, nor to one side, as in facial atrophy. 

Morbid Anatomy and Pathology. — No post-mortem ex- 
amination has yet been made in this disease of the nerves or 
nerve-centres. A microscopical examination of the affected 
muscles made by Dr. Hammond, shows no evidence of degen- 
erative changes of any kind. The nbrillse have been found 
reduced in diameter to about one-third of the natural size, 
and also diminished in length. The internal perimysium, or 
connective tissue of the muscles, is also considerably dimin- 
ished in thickness. So far as the muscles are concerned, 
therefore, there is simply atrophy without degeneration — a 
condition essentially different from what exists in other amy- 
otrophic diseases, such as infantile and adult spinal paraly- 
sis, pseudo-hypertrophic paralysis, and progressive muscular 
atrophy. 

Vulpian refers the trophic disorder of the face to some intra- 
cranial lesion. He says: "This affection is produced in a 
certain number of cases as a consequence of traumatic violence 
inflicted on the head or face. Its development is accompanied, 
in the great majority of cases for several years, with pains of 



PROGRESSIVE FACIAL ATROPHY. 153 

greater or less violence seated in the head, ordinarily toward 
the fronto-temporal region. Sometimes there are spasmodic 
movements of the muscles of the face or of the jaws. In some 
rare cases there has been numbness in the superior extremity 
of the opposite side. These are the circumstances which seem 
to point to a cerebral lesion. But we cannot affirm that such 
lesions exist, while we have no post-mortem examination to 
enlighten us on this point, and while we are embarrassed to 
designate a seat for the lesion, which can reasonably explain 
all the phenomena of the disease."* 

Treatment. — Faradization of the affected parts appears to 
have slightly benefited a few cases, but in the great majority 
of cases neither this nor any other measure has appeared to 
do the least good. 

The remedies which we think would be most likely to prove 
beneficial, are : Argent, nitr., Arsen., Plumbum, Sulphur. 

* Legons sur VAppareil Vaso-moteur, ii, 1875. 



154 INTRACRANIAL DISEASES. 



CHAPTER XIV. 

MYXCEDEMA. 

The term myxedema was first applied by Dr. Ord* to a dis- 
ease characterized by a peculiar form of oedema, or puffiness of 
the skin, over the entire surface of the body. The disease 
closely resembles anasarca, the chief difference being that the 
tissues, instead of pitting on pressure, as in oedema, return with 
prompt and firm resiliency after the pressure is removed. 

Symptoms. — The surface of the body presents an appear- 
ance resembling that of anasarca. When pressed upon, how- 
ever, the tissue is found to be resilient, leaving no indentation 
as in ordinary oedema. 

The cheeks are red from capillary congestion, and the eye- 
lids, nostrils, and lips are swollen and prominent. The swell- 
ing or puffiness may involve, not only the face, but the whole 
surface of the body, and is especially marked in the hands and 
fingers, giving to them a blunted or clubbed appearance ; at 
the same time there is no distortion of the nails. 

There is also well-marked anaesthesia of both the general 
and special senses. The sense of touch is greatly impaired, 
there being not only a feeling of numbness, but a cushioned or 
padded feeling, both of the fingers and feet. The numbness is 
also present in the face, the tip of the tongue, and the upper 
and lower extremities. Sight and hearing, as well as taste and 
smell, are all greatly diminished in acuteness, vision generally 
more or less deranged, and smell sometimes almost abolished. 

The temperature of the body is always below normal; and 
the muscular and coordinating power decidedly weakened. 

* Medico-Chirurg. Trans., vol. lxi, p. 57. 



MYXCEDEMA. 155 

Articulation is slow and indistinct, the grasp feeble, and the 
gait tottering. The patient, although able to stand with the 
eyes closed, requires the aid of sight to coordinate the move- 
ments, and even then they are performed in an awkward and 
uncertain manner. 

The electro-excitability of the muscles is greatly diminished 
in all parts of the body ; the response to both the galvanic and 
faradic currents becoming less and less as the disease pro- 
gresses. 

A characteristic feature of the disease is the mental con- 
dition, which bears a considerable resemblance to acute de- 
mentia, and is accompanied by hallucinations, illusions, and 
delusions. 

The organic functions are all more or less imperfectly per- 
formed. The pulse is irregular, or slow and feeble, the temper- 
ature depressed, the appetite impaired, the bowels constipated, 
the urine loaded with urates, and the sleep disturbed, short, 
and unrefreshing. 

Diagnosis. — The disease may be easily distinguished from 
ordinary oedema, by its never pitting upon pressure. Tricus- 
pid regurgitation, and other cardiac affections interfering with 
the return of blood from the right side of the heart, are at- 
tended with a similar clubbing of the fingers, but the other 
symptoms will prevent any error in diagnosis. The same is 
true of scleroderma, which is liable to be confounded with this 
disease, unless we bear in mind that in the former the surface 
is hard, that there is a sense of constriction about the parts, 
that there are no mental symptoms, nor any permanent reduc- 
tion of temperature, such as is met with in this disease. More- 
over, myxoedema belongs to a much more advanced period of 
life. 

Prognosis. — The prognosis could not be worse than what 
it is, as treatment has hitherto proved utterly unavailing, and 
several cases have terminated fatally. 

Morbid Anatomy and Pathology. — The swelling is caused 
by a mucoid substance deposited throughout the body, but 
more particularly the skin. This mucoid deposit closely sur- 
rounds all the terminal nerves, blunting their sensibility and 



156 INTRACRANIAL DISEASES. 

interfering with their conducting power. Similar deposits are 
also found in the brain and other nerve-centres, and as these 
envelope the nerve-cells, they will serve to explain the im- 
pairment of the mental functions, which occurred in one case 
before there was any appearance of external swelling. 

Treatment. — I am not aware that this disease has ever been 
subjected to homoeopathic treatment. The old school, into 
w T hose hands nearly every case has heretofore fallen, has 
brought to bear upon it its most powerful remedies, such as 
electricity, phosphorus, strychnia, and arsenous acid, but with- 
out improving in the least the nutrition of the parts, or amelio- 
rating the condition of the patient. As such treatment, how- 
ever, is wholly empirical, it does not follow that the homoeo- 
pathic administration of such remedies as Arsenicum, Baryta, 
Carbo an., Iodine, Lachesis, and Silicea, would prove equally un- 
availing. At the same time, it must be confessed that, con- 
sidering what we know of its pathology, it would be highly 
presumptuous to count upon any marked success in the treat- 
ment of this disease, even under the most favorable circum- 
stances. 



CEREBRAL TUMORS. 157 



CHAPTER XV. 

CEREBKAL TUMORS. 

Tumors of the brain differ greatly in size and character, 
some being peculiar to the organ, while others resemble tu- 
mors found in other parts of the body. 

Varieties. — Glioma is the name given by Virchow to a tu- 
mor of the brain due to proliferation of the cerebral connec- 
tive tissue, the neuroglia. These growths, which are found in 
the white substance of the hemispheres, and especially in the 
posterior lobes, sometimes grow to the size of an apple. They 
are of a white or pinkish color, translucent, and either hard or 
soft. The hard, which contain but few cells, resemble fibroma; 
the soft contain numerous cells and nuclei, and have nearly 
the consistence of the brain substance. They are of slow 
growth, and never contain any of the nervous elements. 

Another tumor peculiar to the brain is called psammoma, or 
sand-tumor, so named from the resemblance of its constituents 
to grains of sand. This tumor, which is seldom larger than 
a small cherry, consists of isolated grains of chalky matter 
embedded in the neuroglia. It springs from the dura mater, 
and is mostly found at or near the base of the brain. 

Cholesteatoma, so called because it contains, besides its other 
constituents, cholesterine and stearin e, is also seated at the 
base of the brain. This tumor sometimes reaches the size of a 
walnut, but is generally much smaller. It is made up chiefly 
of epidermoid cells, concentrically arranged, which have un- 
dergone degeneration. It is entirely devoid of blood-vessels, 
has a pearly appearance, and arises sometimes from the brain 
itself, and at others from the cerebral membranes. 

Neuroma, is a small tumor due to hyperplasia of the grey 
substance of the brain. It varies in size from that of a millet- 



158 INTRACRANIAL DISEASES. 

seed to that of a pea. It is found in all parts of the hemi- 
spheres — in the white substance, in the ventricles, and on the 
surface of the convolutions. 

Mucous, lipomatous, cystic, melanoid, and other forms of cere- 
bral tumors, are sometimes met with, but they are not of suffi- 
cient importance to merit a special description in this place. 

The most important forms are those which owe their exist- 
ence to a peculiar constitutional dyscrasia, namely, the cancer- 
ous, the tuberculous, and the syphilitic. 

Cancer of the brain may be of an encephaloid, scirrhous, or 
colloid character, but it generally belongs to the encephaloid 
variety. It usually springs from the dura mater, though it 
may begin in any part or tissue of the cerebrum. "When it 
arises from the external surface of the dura mater, it gradu- 
ally destroys the skull-bones, and eventually bursts forth in 
the well-known form of fungus heematodes, or fungus durse matris. 
When, on the other hand, it springs from the internal surface 
of the membrane, it invades the various structures of the brain, 
following especially the course of the olfactory and optic 
nerves. Finding a ready passage for itself through the bony 
foramina provided for the exit of these nerves, it is very apt 
to appear eventually in the orbit, or in the spheno-maxillary 
fossa. Primary cancer is generally single, and secondary, 
multiple. It is of rapid growth, and is frequently accompa- 
nied with similar deposits in other organs. Histologically, 
these tumors do not differ from cancerous growths in other 
parts of the body. In some cases the cerebral substance near- 
est the cancer undergoes softening, and in others, it remains 
unaltered. 

Tuberculous tumors are mostly confined to children, and are 
generally seated in the hemispheres or cerebellum. When 
single, they often attain the size of a grape or cherry. They 
are generally associated with tuberculous deposits in other 
organs, and undergo similar changes. 

Syphilitic tumors will be described in the next chapter (q. v.). 

Symptoms. — The symptoms common to all cerebral tumors, 
are : headache, vomiting, and optic neuritis ; though it is pos- 
sible for a large tumor to exist in the brain without giving 



CEREBRAL TUMORS. 159 

rise to any symptoms. On the other hand, most cerebral tu- 
mors produce a variety of local and general disturbances, the 
character of which depends upon their nature, size, and seat. 

The first symptom that generally attracts attention is head- 
ache. The pain is usually limited to a particular spot or re- 
gion of the head, corresponding to the situation of the tumor. 
It varies greatly in different cases, being sometimes dull and 
continuous, at others, sharp, lancinating, and paroxysmal. As 
the disease progresses the pain generally becomes more and 
more severe, until in some cases the patient is unable to 
restrain his cries. 

In other cases the patient suffers but little from pain, but is 
drowsy, low-spirited, and irritable. The memory is more or 
less impaired, and there is a general lack of both mental and 
bodily energy. These symptoms become more marked as the 
tremor develops, the mind either gradually sinking into a 
state of melancholy, and finally of complete imbecility, or else 
they give rise to delusions and hallucinations, accompanied 
with attacks of mania ; the patient at last dying comatose. 

Almost every patient suffers more or less from vertigo, and 
also from nausea and vomiting. 

The special senses suffer to a greater or less degree, especially 
the sense of sight. Indeed, several eminent pathologists* assert 
that optic neuritis is an invariable accompaniment of cerebral 
tumors. Both optic nerves are implicated, though one may be 
less affected than the other. The ophthalmoscope also ex- 
hibits atrophy of the optic nerve, which may result primarily 
from the intracranial pressure, or secondarily from the neuritis. 
Hemiopia, diplopia, strabismus, and other ocular troubles, are 
also of frequent occurrence in these cases. 

Paralysis, which is seldom entirely absent, generally takes a 
hemiplegic form, but is sometimes paraplegic. It is frequently 
limited to the muscles supplied by a particular nerve, as the 
third or sixth. It is generally slow in its progress, correspond- 
ing with the growth of the tumor. 

* Annuske, Graefes Archiv., vol. xix, pt. 2, 165. 



1G0 INTRACRANIAL DISEASES. 

Epileptic attacks are common, and may occur either with or 
without loss of consciousness. In the latter case, the convul- 
sive movements are usually confined to one side of the body, 
and occasionally to a single set of muscles, such as those of the 
eye or face. But spasms which commence locally, and ulti- 
mately become bilateral, are generally attended by loss of con- 
sciousness. In these cases, post-epileptic paralysis is generally 
observed. 

Tonic spasms are much less frequently met with in cases of 
cerebral tumor than the clonic form. Their distribution is 
similar to that of clonic spasms. In some they are limited to 
the muscles of the head and neck ; in others the muscles of the 
face and limbs are involved. 

Various other symptoms are sometimes present in these 
cases, such as hyperesthesia, anaesthesia, paresis, tremor, dis- 
turbances of equilibrium, disorders of digestion, assimilation, 
secretion, respiration, and circulation, most of which are plainly 
the result of the cerebral lesion. 

Causes. — Age is one of the predisposing causes in some 
kinds of tumors. Thus, tuberculous tumors are most frequently 
met with in young children ; while aneurismal tumors are 
most common in persons of advanced life. Sex also appears 
to have some influence in this respect, as males are more fre- 
quently affected than females, probably because they are more 
exposed to injury. Heredity is another cause, as shown by the 
various forms of diathetic tumors, which owe their existence 
to constitutional dyscrasise. The chief exciting causes are trau- 
matic injuries, such as blows on the head, falls, etc. Other ex- 
citing causes are: various parasites, such as the cysticercus 
and echinococcus, great mental and physical exertion, cardiac 
hypertrophy, cerebral embolism, and calcareous degeneration. 

Diagnosis. — When, in addition to headache, vomiting, and 
double optic neuritis, a case is attended with frequent epileptic 
attacks, some of which are slight, we are justified, in the ab- 
sence of any symptoms or history pointing to some other form 
of cerebral lesion, in referring the morbid phenomena to intra- 
cranial tumor. Epileptic convulsions occurring late in life 
should always excite suspicion of such a cause, especially if 



CEREBRAL TUMORS. 161 

unilateral, or unattended with loss of consciousness. Very 
limited paralysis,, also, points to this cause, especially if the 
other symptoms correspond. 

The situation of the tumor may often be determined by the 
peculiar character of the symptoms. Thus, when seated in the 
convexity, there is severe headache and epileptic spasms, but no 
anaesthesia or paralysis. When the anterior lobes are affected, 
there is frontal headache, mental excitement, and anosmia. 
When the parietal lobe is involved, there is anaesthesia, with 
slight unilateral paralysis. When the occipital lobes are im- 
plicated, we have intense headache, vertigo, and melancholy, 
but no paralysis. Tumors of the corpus striatum produce 
hemiplegia; of the corpora quadrigemina, ocular paralysis, 
blindness, and hemiplegia ; of the area near the optic chiasm, 
headache, hemiopia, anosmia, paralysis of the ocular muscles, 
and anaesthesia of the parts supplied by the fifth nerve. When 
the cerebellum is affected, the symptoms are occipital head- 
ache, vertigo, and tottering gait. Tumors of the pons Vorolii 
produce paralysis of the muscles supplied by the third, fifth, 
and sixth nerves, difficulty of swallowing, and crossed paraly- 
sis of the limbs. Tumors of the medulla oblongata produce 
convulsions, anaesthesia, defective articulation, difficulty of 
swallowing, paralysis of the bladder, and diabetes mellitus. 

Prognosis. — There is perhaps no class of brain lesions more 
uniformly fatal than that of cerebral tumors. The only excep- 
tion is the syphilitic, which is generally amenable to proper 
constitutional treatment. 

Morbid Anatomy and Pathology. — We have already 
sufficiently described the morbid anatomy of all the principal 
kinds of cerebral tumors, except the aneurismal, which we will 
now consider. 

Aneurismal dilatation of the large cerebral arteries is not 
a very uncommon occurrence, since more than one hundred 
and fifty cases have already been reported, and many more 
would no doubt have been recorded had they not been con- 
founded with apoplexy, or some other form of brain lesion. 

The arteries most liable to be affected are the sylvian and 
the basilar. These aneurismal tumors do not differ in struct- 
11 



162 INTRACRANIAL DISEASES. 

ure from those found in other parts of the system. They 
vary in size from that of a cherry to that of a large plum, or 
even a walnut. They are more common on the left than on 
the right side, probably for the same reasons that embolism 
occurs more frequently on that side of the brain. 

The symptoms of cerebral aneurisms are for the most part 
similar to those of other cerebral tumors producing pressure 
or irritation in the same localities, except that rupture and 
subsequent haemorrhage, which has been observed in about 
one-half of the cases reported, gives rise to symptoms of apo- 
plexy, and proves speedily fatal. 

The pressure produced by cerebral tumors generally, on the 
brain substance, not only causes local symptoms, but in many 
cases leads to fatty degeneration and atrophy of distant parts. 
It also causes displacement of the parts in the immediate 
vicinity of the tumor, renders the cerebral tissue dry and 
anaemic, and causes more or less wasting of the nervous 
structure. 

Treatment. — We have seen that several varieties of cerebral 
neoplasmata consist of hypertrophied connective tissue, pro- 
ducing a condition similar to that known as cerebral sclerosis. 
Now, as Baryta carb., Baryta mur., Baryta iod., are of undoubted 
value in the treatment of the latter affection, it is highly prob- 
able that the same medicines will render good service in the 
former. These remedies may very properly be given in all 
cases in which we have reason to suspect the presence of a 
solid tumor in the brain, as being most likely to meet the pa- 
thological indications. At the same time, we may, by admin- 
istering such remedies as cover the totality of the symptoms, 
best relieve the various functional disturbances produced by 
the adventitious growths, and thus contribute materially to the 
comfort and welfare of the patient. In this way the epileptic 
seizures may be rendered lighter, the pains less intense, and 
even the paralytic symptoms may be measurably modified and 
relieved. Whilst, therefore, there is but little room for encour- 
agement in these cases, so far as ultimate recovery is con- 
cerned, they should not be looked upon in all cases as utterly 
hopeless, as some of our remedies have proven successful under 



CEREBRAL TUMORS. 163 

circumstances apparently no more favorable than these. Take 
Silicea, for example, which has not only removed diabetic symp- 
toms in a number of instances, but relieved the pains of cancer, 
and caused the shrinkage of fibroid tumors. In addition, 
therefore, to the treatment recommended under hemiplegia, epi- 
lepsy, convulsions* and cerebral atrophy (q. v.), a careful study 
should be made of the following 

General Indications. — Atheromata. — Bell., Calc, Graph., 
Sil., Sulph., Thuja. 

Cysts. — Apis., Arsen., Apocyn., Sil. 

Hxmatomata. — Arm, Con., Iod., Sulph. 

Lipomata. — Bar., Calc, Croc, Graph., Lapis alb., Phos., 
Phyt. 

Fibrous. — Bar., Bell., Calc, Con., Sil. 

Fibro-Scirrhous. — Ars., Ars. iod., Aur., Carb. an., Con., Cal., 
Lapis alb., Nit. ac, Sil. 

Melanoid. — Phos., Sang., Sil., Thuja. 

Colloid. — Carbol. ac, Hydr., Phos. 

Fungoid. — Ars., Carb. an., Nit. ac, Phos., Sil., Staph., Sep., 
Thuja. 

* See Nervous Diseases, p. 27. 



164 INTRACRANIAL DISEASES. 



CHAPTER XVI. 

CEREBRAL SYPHILIS. 

When we consider the prompt effect which appropriate med- 
ical treatment has upon syphilitic diseases of the brain, we are 
not surprised to find that the characteristic lesions are not of 
an inflammatory character, as was formerly supposed, but are 
generally localized, the membranes and substance of the brain 
not being, as a rule, profoundly affected. Not only have nu- 
merous cases occurred in which no lesions could be discovered 
after death, but Heubner asserts that there is no case on record 
in which the existence of ordinary meningeal inflammation 
could be established by microscopical evidence; while Dr. 
Dowse,* one of the latest investigators of this subject, says that 
the share taken by the proper nervous elements in the patho- 
logical changes which affect the nervous system in these cases 
is extremely limited. 

Varieties. — There are three principal forms or varieties of 
syphilitic lesions of the brain, namely, the congestive, the vascu- 
lar, and the syphilomatous. 

1. The congestive form of cerebral syphilis exhibits scarcely 
any anatomical changes, unless the disease has lasted for a 
considerable period, and even then they are not very marked, 
the membranes having simply lost their transparency, and the 
cerebral convolutions appearing to be slightly atrophied. 

2. The vascular form affects the cerebral arteries, especially 
the carotids, and the arteries at the base of the brain. The 
vessel changes from a translucent, pinkish color, to a greyish- 
white ; is reduced in diameter by a greyish deposit between 

* Syphilis of the Brain and Spinal Cord, 1879. 



CEREBRAL SYPHILIS. 165 

the endothelium and the elastic coat of the vessel; and finally 
becomes completely occluded by the syphilitic thrombus, con- 
sisting of endothelial cells developed by proliferation into con- 
nective tissue. 

3. The syphiloma, or syphilitic tumor, commonly called gumma, 
consists of two varieties, the soft and the hard. 

The soft gumma has the appearance of greyish-red gelatin, 
and consists of round cells and nuclei, mixed with branched, 
stellate, and spindle-shaped cells, and enlarged capillary vessels. 

The hard gumma, wmich is probably only an advanced stage 
of the soft, is of a cheesy consistency and well-defined outline. 
It is devoid of cells or of blood-vessels, being dry, yellow, and 
homogeneous, except near the border, where there are occa- 
sional oil-globules, interspersed with pigmentary granules and 
crystals. This tumor varies in size from that of a filbert to 
that of a walnut, or even larger ; and not unfrequently appears 
to be moulded by the shape of the parts where it is located, as 
though originally in a soft condition. 

Symptoms. — The symptoms of the hyperxmic form of cere- 
bral syphilis are at first of a fleeting and somewhat indefinite 
character. The mind is either unduly excited or depressed ; 
and although there is at first no marked mental unsoundness, 
there is more or less eccentricity of manner, confusion of 
thought, and delusion. The general health also suffers, pass- 
ing gradually from a state of simple debility to one of paresis 
and nervous prostration, accompanied with trembling of the 
tongue when protruded, embarrassment of speech, unequal 
pupils, tottering gait, formication, and numbness. Fresh 
syphilitic outbreaks are apt to occur from time to time; and 
these are usually attended by an aggravation of all the symp- 
toms, mental as well as physical. Paralytic attacks of aphasia, 
hemiplegia, and paraplegia, become more and more frequent 
and permanent ; the general debility increases ; and, unless 
the disease is speedily arrested by treatment, the patient dies 
within a few days, from the effects of cystitis, decubitus, and 
nervous exhaustion. 

The symptoms of the vascular form differ according as the 
disease affects the cortical or the basal sphere of nutrition. In 



1G6 INTRACRANIAL DISEASES. 

the former case, there is generally a gradual narrowing of the 
affected arteries, giving rise to debility, impairment of the 
mental faculties, and, in many cases, to somnolency, which 
may deepen into the apoplectic seizure. But in the basal 
form, the symptoms are usually much more rapidly developed. 
Sometimes there is multiple thrombosis of one or more of the 
basal arteries, in which case the patient generally dies suddenly, 
with all the symptoms of cerebral apoplexy. In other cases, 
there are premonitory symptoms, especially ocular troubles, 
such as ptosis, diplopia, and amblyopia ; or the irritation may 
involve other cranial nerves, producing spasm of the sixth and 
seventh nerves, or hyperesthesia and anaesthesia in certain 
branches of the fifth nerve. Hemiplegia may afterwards 
gradually set in, attended or not with aphasia, but without 
loss of consciousness. The patient gradually grows worse, be- 
comes somnolent, suffers from headache, confusion of mind, 
and other head symptoms, and, unless relieved by treatment, 
will finally die, notwithstanding temporary intervals of im- 
provement. 

The symptoms attending the development of cerebral syphi- 
loma are somewhat peculiar. One of the most characteristic is 
an intolerable headache, which occurs in paroxysms, and is 
most intense at night. The paroxysms last for several weeks, 
when they remit for a while, and are again succeeded by a 
fresh attack ; and thus it may continue, unless relieved by 
treatment, for several years. After a time epileptic seizures 
occur; or there may be unilateral attacks of convulsions, with- 
out loss of consciousness. In this case, the spasms are probably 
due to irritation of the surface of the opposite hemisphere. The 
patient now becomes more or less irritable, and either mentally 
excited or depressed. The mind gradually becomes impaired, 
the speech slow and embarrassed, and sometimes aphasic symp- 
toms make their appearance. Unless relieved by treatment, 
symptoms of muscular paresis and incoordination set in; the 
grasp becomes weak and uncertain, and the gait irregular and 
tottering. Frequent epileptic attacks occur, which, becoming 
more and more severe, are at last followed by coma, exhaus- 
tion, and death. 



CEREBRAL SYPHILIS. 167 

Causes. — Cerebral syphilis, like every other form of the 
affection, is due to a specific poison affecting the constitution ; 
and belongs for the most part to the tertiary stage, or to the 
latter part of the second stage. It is invariably preceded by a 
hard infecting chancre, the cerebral symptoms not manifest- 
ing themselves in many cases until after the lapse of several 
months or years. In some instances, however, they show 
themselves as early as the beginning of the second stage, or 
soon after the appearance of the rash or angina. All ages are 
subject to it, but it is most common between the ages of twenty 
and forty years. Males are more liable to it than females, 
constitutional syphilis being more common in men than in 
women. 

The chief predisposing causes appear to be, an incomplete 
or unsuccessful medical treatment, and what is known as the 
neuropathic constitution. The latter may be either heredi- 
tary or acquired. In these cases, the ancestors or immediate 
relatives are found to have suffered more or less from epi- 
lepsy, chorea, neuralgia, and other nervous diseases. What- 
ever weakens the nervous system, such as severe mental labor, 
sexual excesses, or too free indulgence in the use of alcholic 
liquors, will also act as an exciting cause. Dr. Dowse says, 
"I have clearly traced a cerebral syphilis when the exciting 
cause has been venereal excesses, over-study, mental anxiety, 
worry, and even fright."* Mechanical injuries of the brain, 
such as are produced by blows or falls upon the head, will also 
favor the development of cerebral syphilis. 

Diagnosis. — The previous history of the patient constitutes 
one of the most important factors in the diagnosis. Age is also 
of great diagnostic importance, as paralysis occurring in youth- 
ful persons is, in the great majority of cases, of syphilitic origin. 
Violent proxysmal headache is another characteristic symptom 
of the disease. There is no form of headache so intense as that 
which results from syphiloma of the dura mater. The pain 
is not only very intense, but is localized, remittent, and in- 
creased by pressure. The reverse of this, however, is the case 

* Op, cit. } p. 17. 



168 INTRACRANIAL DISEASES. 

when the pia mater is involved; the pain is never intense and 
is never localized, but is diffused over the forehead, and of a 
dull, aching, congestive sort. The temperature, on the con- 
trary, is higher in these cases, and there is greater constitu- 
tional disturbance. 

In case the patient has no clear syphilitic history, the differ- 
ence between the real and apparent age, the facial expression, 
and especially opthalmoscopic symptoms, are generally suffi- 
cient to clear up the case. These symptoms consist in swelling, 
hyperemia and oedema of the papilla, varicosity of the veins, 
and a peculiar form of neuro-retinitis and choroiditis. There 
may also be optic atrophy, but this is the least certain of all 
the ocular changes which occur in syphilis, and should there- 
fore not be relied upon as a diagnostic symptom. 

Syphilitic thrombrosis is perhaps the most difficult form of 
cerebral syphilis to diagnose. Dr. Dowse says : " It is peculiar 
to syphilis that the subsidence of the symptoms is rapid, whilst 
their invasion is comparatively slow. A man free from syph- 
ilis goes to bed, and overnight has felt quite well, but finds in 
the morning that he cannot move his arm or leg. This mode 
of attack is rarely the case where the lesion is due to syphilis. 
A syphilised patient, without premonitory warning of any es- 
pecial kind, may have an epileptic fit, but he will not without 
warning fall in an apoplectic fit. This does not imply that he 
will not have a fit of apoplexy ; but for some days, or it may 
be weeks, previous to this calamity, he will be heavy and leth- 
argic, although he is not able to sleep; he is restless, and all 
his doings and movements are without any definite purpose ; 
he may not eat unless requested to do so, or if he sits down to 
partake of a meal, he rises before he has finished, and his knife, 
fork or glass may suddenly fall from his hand, or his hand 
may shake so that he is unable to carry a glass to his mouth, 
or if he does so, it rattles against his teeth, and the fluid escapes 
at the corners of his mouth, of which he is, in a measure, un- 
mindful ; and, finally, he may neglect and appear to be regard- 
less of, the calls of nature. It is after symptoms such as these 
that the man with syphilitic arterial changes is usually found 
breathing stertorously and in a comatose, apoplectic state. 



CEREBRAL SYPHILIS. 169 

There may be subsequent convulsions, or there may not, and 
the comatose state may be slight, or it may be profound ; the 
comatose condition is the more usual, and it resembles a deep 
stupor, out of which the patient may be roused by pinching or 
pricking, to a state of apparent subjective consciousness, which 
is only a grade, however, beyond the mere automatic. He 
may continue in this state for one or two weeks, or, as I have 
seen cases, for three weeks ; and then, with returning con- 
sciousness, the paralysis disappears, the intellect brightens, and 
he may even, for a time, so far recover as to be able to attend 
to his business or professional pursuits, but after this there is 
rarely a return of the evanescent forms of paralysis previously 
noted. After an attack of this nature, when paralysis super- 
venes (and it is very rarely that it does not, sooner or later), 
it is usually persistent and permanent, and death may take 
place during an attack similar to that just noticed, or it may 
be preceded by a series of epileptiform seizures, ending in 
profound coma."* 

Prognosis. — Syphilis generally yields more readily and rap- 
idly to appropriate medical treatment than any other form of 
brain disease. Not that every case of cerebral disease that has 
syphilis for its origin may be rapidly and thoroughly cured, 
for there is many a cerebral paralysis due to syphilis, which 
will not readily yield to specific measures; but as a rule, 
syphilitic lesions of the brain, like those of other organs, are 
quite amenable to treatment. Much, however, depends upon 
the situation and degree of the disease, as well as upon the 
means adopted. 

Morbid Anatomy and Pathology. — The morbid anatomy 
of syphilitic cerebral lesions has to some extent already been 
given. The anatomical features of syphiloma are thus given 
by Rindfleisch : " Its specific anatomical character does not 
reside in any marked deviation of the gummatous tissue from 
the familiar types of inflammatory growth, but rather in the 
circumscription of a more or less spheroidal nodule in the 
midst of a larger deposit of newly-formed embryonic tissue, a 

* Op. tit, p. 38. 



170 INTRACRANIAL DISEASES. 

nodule which differs from the embryonic tissues round it in 
the farther course of its metamorphoses. For while the-latter 
undergo conversion into fibroid tissue, forming a cicatrix char- 
acterized by a tendency to extreme contraction, the former, 
retaining the circular form of its cells, and occasionally pro- 
ducing an anastomotic network of corpuscles, materially un- 
dergo a necroid transformation of its intercellular substance. 
The cells grow fatty, their place is taken by round or stellate 
aggregations of fat granules, which appear to be capable of 
lasting as such for long periods of time. The final result is a 
yellowish-white rounded nodule, of a soft and elastic consist- 
ency, embedded in a deposit of newly-formed connective tis- 
sue. This is the specific tumor of syphilis, the " Tophus or 
Gumma Syphiliticum." 

Dr. Dowse * sums up the essential, gross pathological feat- 
ures of these lesions as follows : " They include (a) the inflam- 
matory thickening of the membranes. This thickening may 
originate in the lining membrane of the osseous system with 
which the nervous structures come into contact, (b) The 
invasions of the neuroglia, or connective tissue, by a diffuse 
form of gummatous infiltration, which might be the result, 
primarily, of disease of the circulatory system, or alterations 
of the fluids circulating within the vascular channels of the 
nervous tissue. The lacter condition gives rise to albumino- 
fibroid changes, more especially in the white nerve substance, 
and is often associated with a low form of inflammation of the 
membranes, (c) The appearance of syphilomatous masses, 
which often occur singly, but may be numerous. Their seat 
may be over the surface of the hemispheres, and I have usually 
found them in the upper convolutions of the anterior lobes, or 
they may occur at the base. At any rate, they are to be seen 
almost invariably at the cortex, and closely united with the 
membranes. They extend into the surrounding tissue, which 
is generally found to be softened, hypervascular, and of a faint 
yellow color. When examined, they present the appearances 
which have been previously noted, the nerve-cells and vessels 

* Op. cit., p. 95. 



CEREBRAL SYPHILIS. 171 

giving evidence,, under the microscope, of the usual degenera- 
tions consequent upon vascular occlusion."' The same author,. 
who caused a microscopic examination to be made of a longi- 
tudinal section through a capillary vessel of the second left 
frontal convolution, found the coats separated, and in some 
parts almost obliterated,, by an aggregation of small cells or 
nucleor growths. This invasion involved the inner rather 
than the outer tunics of the vessel, a point upon which Heub- 
ner lays great stress as being especially diagnostic of their 
syphilitic origin. 

Treatment. — The treatment of syphilitic affections of the 
brain is of two kinds, namely, symptomatic and specific. 

The symptomatic treatment does not differ essentially from 
that given under the heads of cerebral hyperemia, thrombosis, 
and tumors (q. v.). 

The specific treatment consists mainly in the prompt and 
judicious administration of anti-syphilitic remedies, such as 
Kali iodatum, Mercurius corrosivus, Arsenicum iod., Aururu, 
Corydalis, Mezereum, Phytolacca, Stillingia. 



172 INTRACRANIAL DISEASES. 



SECTION II. 

MENINGEAL AFFECTIONS. 

CHAPTER I. 

SIMPLE ACUTE MENINGITIS. 

This disease is a lepto-meningitis cerebralis, or simple acute 
inflammation of the pia mater of the brain. It may be par- 
tial, general, or limited to either the convexity or base of the 
brain. 

Symptoms. — Owing to the fact that the inflammation, 
instead of seizing at once upon the entire membrane, generally 
advances gradually from one point to another, different stages 
of the inflammatory process are apt to exist at the same time 
in different parts of the diseased membrane. Consequently, 
the two stages of irritation and depression are not, as a rule, 
so sharply defined as to serve as a reliable basis for descrip- 
tion. Neither is it practicable to give all the groupings of 
symptoms met with in the various forms of the disease. 

The symptoms are found to vary considerably in different 
cases, according as the disease is of primary or secondary 
origin ; they are also greatly influenced by the seat, extent, 
and intensity of the inflammatory process, as well as by the 
age of the patient. When primary, the disease is generally 
ushered in by severe chills, intense headache, and high fever; 
and is attended by more or less delirium, convulsions, or 
maniacal excitement. In other cases it assumes a somewhat 
latent form, being accompanied with only slight symptoms, 
or at most with depression and paralysis. 



SIMPLE ACUTE MENINGITIS. 173 

In infancy the attack usually sets in after a period of rest- 
lessness, with convulsions, high temperature, and very quick 
pulse. The large fontanelle pulsates and is tense. The convul- 
sive seizures follow each other with greater or less frequency, 
the child remaining weak and somnolent between them. At 
last the patient sinks into a state of coma, followed by paraly- 
sis. Older children often remain excited to the end, scream- 
ing, vomiting, and complaining of cephalalgia, intolerance of 
light, and other evidences of cerebral disturbance. 

In adults, severe headache is one of the most constant 
symptoms, especially when the disease is confined strictly to 
the pia mater. The patient moans, screams, grasps the head 
with his hands, complains of stitches and lancinating pains 
through the head, and exhibits an expression of intense suf- 
fering. There is photophobia, tinnitus aurium, hyperesthesia, 
and increased reflex excitability. If the skin be ever so lightly 
irritated, it is apt to break out into patches of erethematous 
redness. In other cases the symptoms are simply those of 
maniacal excitement, without any marked increase of tem- 
perature, or other evidence of fever. This is most likely to 
occur if the disease is complicated to any considerable extent 
with inflammation of the brain substance {meningo-cerebritis), 
in which case the patient is apt to be simply restless, sleepless, 
and subject to mental hallucinations, which may pass into 
muttering delirium. In either case, however, the patient 
sooner or later sinks into a state of stupor and indifference, 
accompanied or followed by muscular tremors, convulsions, 
paralysis, coma, and death. 

Tonic contractions of certain muscles, especially those of the 
head and neck, occur in these cases, by which the parts are 
drawn backwards or to one side; the arms also are sometimes 
similarly affected ; and there may be a condition of trismus. 
The limbs are always greatly weakened, but although they 
may become paralyzed, there is seldom hemiplegia or paralysis 
of the sphincters. Towards the last, however, it is not uncom- 
mon to have incontinence of urine and faeces. At this time, 
also, other typhoid symptoms predominate. The tongue is 
thickly coated, or brown and dry ; deglutition is difficult, the 



174 INTRACRANIAL DISEASES. 

pulse is slow, or quick and irregular; the respiration is dis- 
turbed, sighing, and more or less uneven ; the temperature is 
high and variable ; and the skin is hot and dry, or else bathed 
in a copious perspiration. 

The pupils vary greatly at different stages of the complaint, 
being sometimes contracted, at others dilated, and occasionally 
of unequal size. As a general rule they are either contracted 
or of a medium size during the stage of excitement, and dilated 
or unequal towards the close, or during the stage of depres- 
sion. They may, however, be either dilated or contracted 
during the whole course of the disease. 

The pulse and temperature also vary considerably, the 
former being at first large, hard, and frequent, reaching as 
high as 140 or 150 per minute, afterwards falling to 60 or less, 
but towards the close becoming frequent again, though small 
and irregular. The temperature, which at first is increased, 
afterwards becomes lowered, the mercury indicating a range 
of from 94° to 104° F. 

Thirst, anorexia, and vomiting, which are nearly always 
present at the beginning, sometimes continue throughout the 
disease, or reappear from time to time during its course. 

Morbid Anatomy. — At first, the only morbid appearance 
that presents itself is the redness of hyperemia, resulting from 
a more or less uniform injection of the capillary vessels of the 
pia mater. At a later period, there is congestion of the larger 
vessels, together with an effusion of fibrine, white blood-cor- 
puscles, and serum into the subarachnoidal space, which soon 
becomes turbid or yellowish, and finally changes into pus. 
The effusion is greatest in the vicinity of the larger blood-ves- 
sels, lines of pus being especially conspicuous along the course 
of the parietal veins, or spread out in the form of thin mem- 
branous patches beneath the arachroid. The inflammatory 
products may be limited to the convexity and lateral portions 
of the hemispheres ; or they may be confined to the base of the 
brain ; or they may involve the entire surface of both regions. 
When the inflammation is general, and also when limited to 
the basal region, the ventricles usually contain more or less 
fluid, and the central parts of the brain are generally softened ; 



SIMPLE ACUTE MENINGITIS. 175 

but when the convexity alone is affected, the ventricles are apt 
to be dry and empty, even though the cerebral cortex should 
be involved in the inflammatory process. 

Pathology. — It is generally conceded that the symptoms 
of irritation, or those that belong to the initiatory stage, are 
due to congestion; and that those of depression, met with in 
the later stages of the complaint, are caused mainly by effusion 
and the resulting pressure. 

As to the starting point of the disease, it doubtless lies in 
the vascular system, but whether excited by the presence of 
minute emboli, thromboses, or capillary ruptures, is an un- 
settled question. When we consider the prevalence of the 
disease among cachetic subjects, and its frequency in cases of 
rheumatism, endocarditis, and erysipelas of the head and face, 
we cannot doubt that it often originates in one or the other of 
these modes, even though the primary histological changes 
have as yet escaped detection. 

Causes. — As a primary affection, the disease is most fre- 
quently due to cold and dampness, or to prolonged exposure 
to furnace-fires, or to the heat of the sun. The disease is most 
apt, however, to occur in connection w T ith, or immediately 
after, some other acute affection, such as the various exanthe- 
matic fevers, small-pox, rheumatism, pleurisy, pneumonia, etc. 
It is frequently associated with erysipelas of the head and 
face, especially in its later stages. It is also sometimes met 
with in Bright's disease of the kidney, in typhoid fever, and 
in broken-down states of the system, whether arising from 
dyscrasia, or from the decreptitude of old age. 

Sex appears to exercise considerable influence in its pro- 
duction, as it occurs much more frequently in males than in 
females, probably in consequence of the former being more 
exposed to the influence of syphilis and other exciting causes. 
While not confined to the period of infancy and childhood, 
it is much more rarely met with after the age of twenty than 
before. 

Diagnosis. — Simple meningitis is most liable to be con- 
founded with the tubercular variety of the disease. The pres- 
ence or absence of a tubercular constitution, the general 



176 INTRACRANIAL DISEASES. 

history of the case, and the conditions under which the disease 
is developed, will often throw much light upon the case. The 
temperature frequently rises higher in simple meningitis than 
it does in the tubercular form, which latter seldom exceeds 
100° or 101° F. Other symptoms, also, are usually less prom- 
inent in the tubercular form, such as delirium, retraction 
of the head, etc. On the other hand, tubercular meningitis is 
of much greater frequency than the simple form, though the 
proportion of males to females is considerably greater in the 
latter. 

Prognosis. — The prognosis is always unfavorable, at least 
nine out of every ten cases proving fatal within the first three 
weeks, and the great majority succumbing within the first ten 
days of the disease. Patients, however, sometimes make good 
recoveries from it, as shown by the subsequent post-mortem 
appearances of persons dying from other diseases. 

Treatment. — The treatment required in the initial stage of 
simple cerebral meningitis is identical with that of hyper semia 
of the brain (q. v.). After this brief period has passed, and the 
period of depression has set in, the chances of recovery are 
indeed small, but the treatment, if strictly homoeopathic, may 
yet be crowned with success. 

General Indications. — Aeon., iEsc. gl., Apis, Bell., Bry., Camph., 
Canth., Cimicif, Cin., Coca, Cup., Dig., Gels., Glon., Hell., Hyos., 
Lach., Merc, Op., Stram., Sulph., Tart, em., Verat. vir. 

In Infants. — Aeon., Apis, Bell., Cin., Glon., Hell., Lach., Merc. 

In Erysipelas Cases. — Apis, Bell., Lach., Merc, Phos., Rhus, 
Verat. vir. 

Heat or Sunstroke. — Arm, Bell., Camph., Gels., Glon., Lach., 
Scutel., Therid. 

Exposure to Cold. — Aeon., Bell., Bry., Dulc, Gels., Rhus. 

Exanthematic Fevers. — Aeon., Apis, Bell., Lach., Merc, Rhus, 
Sulph., Verat. vir. 

Special Indications. — Aconite. — Inflammatory fever, with dry, 
burning heat of the skin ; red and inflamed eyes ; burning, 
throbbing, or lancinating pains through the whole head ; pulse 



SIMPLE ACUTE MENINGITIS. 177 

full and hard ; anxiety and fear of death, or delirium with 
great anguish ; vomiting of bile ; convulsions, or tonic con- 
tractions, with tendency to paralysis ; pupils contracted or 
dilated. Especially indicated at the commencement of the 
disease, and also in erysipelas cases. 

jEthusa cyn. — Stinging, lancinating pains through the head ; 
obstinate vomiting ; tetanic convulsions; staring eyes ; pupils 
dilated and insensible ; drawing in the nape of the neck ; face 
pale and collapsed ; coma ; pulse small and frequent, with 
cold skin. 

Apis met. — Infantile cases, with delirium, loss of conscious- 
ness, and occasional shrill screams; bending back and rolling 
of the head ; squinting of the eyes ; dilated pupils ; child puts 
its hand to its head while it screams, even when unconscious ; 
face pale, or marked with red streaks and spots ; scanty or sup- 
pressed urine ; stool thin and scanty, or suppressed ; very 
frequent and weak pulse, or else slow and irregular ; convul- 
sions, trembling of the limbs, and paralysis. Apis is not only 
suitable to infantile cases, but also to those preceded by, or com- 
plicated with erysipelas. 

Arsenicum. — Stinging and lacerating pains in the head ; 
staring eyes, with dimness of vision and altered pupils ; burn- 
ing and swollen skin, with or without moisture ; rapid, feeble, 
and intermitting pulse ; vertigo, delirium and insensibility ; 
tonic spasms, Allowed by paralysis. Especially suited to the 
last stage. 

Belladonna. — Burning, stinging, or lancinating headache ; 
red and sparkling eyes, with distorted orbs ; face and skin red, 
burning, and swollen ; violent delirium ; frequent vomiting ; 
small and quick, or intermitting pulse ; loss of consciousness, 
spasms, paralysis, and relaxation of sphincters. Especially 
suited to children, and to cases complicated with erysipelas. 

Bryonia. — During the first stage, with sharp and violent 
pains in the head, red and inflamed eyes, quick and hard 
pulse, hot and burning skin, vertigo, delirium, cramps, and 
convulsions; or else at a later period, with sopor, dim and 
glossy eyes, slow and irregular pulse, cold, pale, moist skin, 
dry lips, and dry and brownish tongue; other symptoms are, 
12 



178 INTRACRANIAL DISEASES. 

bending of the head backward, constant motion of the jaws, 
and constipation. 

Cantharides. — Sharp, lancinating pains in the head; great 
heat of skin, with fiery, sparkling and distorted eyes, and full 
and hard pulse; vertigo, delirium, or insensibility; tonic 
spasms and convulsions. This remedy is especially indicated 
in cases following the retrocession of erysipelas of the head 
and face. 

Cina. — Violent headache in the forehead and occiput; burn- 
ing heat, especially in the face, or with red cheeks contrasting 
strongly with pallor about the nose and mouth ; child cross 
and peevish; quick and irritable pulse; screams and startings 
in sleep; vertigo; vomiting; white, milky-looking urine; de- 
lirium, cramps, and convulsive movements. Suited to either 
real or pseudo-meningitis when attended with worm symptoms. 

Cuprum. — Head hot, with sharp, lancinating pains shooting 
through it; consciousness with vertigo, or delirium with 
stupor; tonic spasms and convulsions; red and inflamed eyes 
with rolling orbs; quick and strong pulse, together with more 
or less vomiting; but the remedy is better suited to the last 
stage, attended w 7 ith slow, small and weak pulse, blue, shrunken 
face, suffocative breathing, dimness of vision, moist hands, 
and paralysis. 

Digitalis. — Stupor, gradually deepening into coma; small 
and slow pulse; dilated pupils, with insensibility of vision; 
general or partial convulsions; labored breathing; irregular 
action of the heart, sometimes very weak, at others strong; 
particularly adapted to the last stage. 

Gelsemium. — Intense congestion of the brain, especially in 
teething children; severe pain in the occiput; head hot, with 
redness of the face; nausea, with blindness; child drowsy, 
and wants to be let alone; frequent startings in sleep; con- 
stant internal fever, though without thirst, and the feet and 
hands cool and moist. 

Glonoin. — Extreme cerebral congestion, attended by the 
most intense headache, flushed face, full and rapid pulse, red, 
hot and staring eyes, photophobia, ringing in the ears, beating 
of the temporal arteries, nausea and vomiting; stupor, with 



TUBERCULAR MENINGITIS. 179 

sunken eyes, slow, irregular pulse, and cool and moist skin. 
This remedy is suited to every stage of the complaint, pro- 
vided it is used sufficiently high. 

Helleborus. — Violent headache, especially in the occiput; 
head drawn back, with stiffness of the cervical muscles; eyes 
staring and oblique; face pale and cedematous; forehead con- 
tracted, and covered with cold perspiration; frequent starting 
and screaming during sleep; working of the jaws, the lower 
one depressed; breathing irregular, sometimes quick, at others 
slow and deep, or sighing; jerking of the limbs, with convul- 
sive movement of individual muscles. 

Hyoscyamus. — Delirium, gradually passing into stupor and 
coma; sticking paius in the head, with red, burning face, red 
and sparkling eyes, contracted pupils, and full, strong, and 
quick pulse; or else loss of consciousness, cold and pale face, 
dilated pupils, weak and intermitting pulse, and paralysis. 

Mercurius.- — Drowsiness with great, restlessness; frequent 
vomiting; starting and screaming in sleep; pupils dilated or 
uneven; pale and shrunken countenance; skin covered with 
perspiration; respiration irregular and difficult; retention or 
inconstancy of stool and urine. 

Opium. — Stupor and insensibility; stertorous breathing; 
pulse small, weak, and irregular; frequent vomiting; pupils 
dilated ; eyes half open ; when aroused, patient immediately 
relapses into a state of insensibility; urine suppressed. 

Rhus tox. — Sticking pains in the head ; inflamed and swollen 
eyes ; red and burning face ; wild delirium, or slow and indis- 
tinct muttering ; cramps, numbness, and paralysis. Especially 
suited to cases complicated with erysipelas of the head and 
face. 

Stramonium. — Violent delirium accompanied by frightful 
screams ; head drawn backward ; convulsive movements of 
the limbs; conjunctiva injected; face red; great dryness of 
the mouth ; vomiting, constipation, and retention of urine; 
sleep almost natural, but on being aroused the patient does 
not recognize his friends. 

Sulphur. — Often indicated as an intercurrent remedy, es- 
pecially after Bryonia, Cuprum and Rhus. 



180 INTRACRANIAL DISEASES. 



CHAPTER II. 

TUBERCULAE MENINGITIS. 

Syn. : Acute Hydrocephalus. 

Tubercular meningitis is a peculiar and very fatal form of 
lepto-meningitis, due to a deposit of tubercular granules in the 
pia mater at the base of the brain. For many years it was 
supposed to be peculiar to infancy and childhood, but it is 
now known to manifest itself occasionally as a complication 
of chronic phthisis in. adult life. Nevertheless, the affection 
occurs with such special frequency during infancy and child- 
hood, as to fully entitle it to be still regarded as a disease of 
early life. 

Symptoms — Although somewhat arbitrary, the symptoms 
of tubercular meningitis may be most usefully and conveni- 
ently arranged in four periods, or stages : 1. The prodromic 
or formative stage ; 2. The stage of irritation or excitement; 3. 
The stage of depression ; and 4. The stage of paralysis. 

1. The Prodromic Stage. — The symptoms belonging to this 
stage may be very slight or altogether wanting, but generally 
they are sufficiently well marked to attract attention, and in 
some cases, especially in very young children, they are so pro- 
nounced as to exhibit the characteristic features of the full- 
formed disease at the very outset. As a general rule, during 
this stage the child appears listless and drooping; is more or 
less feverish and irritable ; suffers from occasional headache- 
looses flesh; is dizzy, sleepless, pale, and occasionally has a dry 
cough. The appetite is capricious and irregular, and there is 
occasional vomiting. Sometimes the abdomen is tumid, and 
the patient suffers from alternate attacks of diarrhoea and con- 
stipation. The alvine discharges are seldom of a perfectly 



TUBERCULAR MENINGITIS. 181 

healthy character. The tongue is moderately furred and 
quite moist. The skin is almost always preternaturally dry; 
and although there is seldom any well-marked febrile move- 
ment, flashes of heat alternating with chills are apt to occur 
from time to time. The pulse sometimes slackens or inter- 
mits, and this is found to occur most frequently at the seventh, 
ninth, and sixteenth beats. This irregularity of the pulse is a 
highly characteristic symptom of the disease, and is met with 
in every stage. The face, which is generally of an unhealthy 
color, is sometimes red and sometimes pale. The eyes are 
more or less dim, and frequently look anxious and amazed, 
especially after waking. The gait is generally awkward and 
heavy; and the muscular system having lost its tone, the 
patient soon becomes exhausted. These symptoms are seldom 
all present in the same case, or at the same time, and those 
which are, often intermit, coming on at about the same hour 
every day, so as frequently to be mistaken for those of hydro- 
cephaloid, or of ordinary infantile fever. Very young children 
are apt to be exceedingly restless, sensitive to light and noise, 
frequently scream out suddenly, refuse the breast, bend the 
head and trunk backward, or grasp at the head as if in pain, 
exhibiting, as before stated, the symptoms of the second, or 
full- formed stage, at the very outset. This stage varies greatly 
in duration in different cases, sometimes lasting only a few 
days, but occasionally protracted over a period of several 
weeks, or even months. 

2. The Stage of Excitement. — After a longer or shorter period, 
the stage of high irritation or excitement sets in. There is 
great restlessness and anxiety, with undue heat of the head ; 
and if the child is old enough, he complains of violent head- 
ache, and frequently cries out, "Oh, my head !" The carotids 
are now seen' to throb violently; the eyes, which are turned 
up, are painfully sensitive to the light; and the pupils, though 
generally contracted, are sometimes exceedingly variable. 
The tongue is usually covered with a dirty ish- white or brown 
coat ; the appetite is lost ; vomiting, generally of bile, occurs 
from time to time ; and there is unquenchable thirst. At the 
same time, there is marked emaciation, with pain in the limbs 



182 INTRACRANIAL DISEASES. 

and abdomen, and the latter is retracted. The stools are gen- 
erally green or dark-colored, and constipated. The urine is 
greatly diminished in quantity, and either high-colored, or 
turbid, with whitish sediment. The skin is more or less re- 
laxed, especially about the forehead, and of a dingy-white 
color ; and the face, which is pale, is either sunken or swelled. 
The pulse is generally slow and intermitting, but occasionally 
regular. The breathing is frequently hurrier', irregular^and 
interrupted by moans. Patients usually have a wandering 
look during this stage, cry out from time to time, and occa- 
sionally grate their teeth. The decubitus is on the side, with 
hand to the head. Convulsions sometimes occur, and may be 
repeated several times in succession. The temperature is con- 
siderably elevated, ranging from 101° to 103° F. The symp- 
toms still continue to vary in violence at times, and are some- 
times greatly abated. This is especially apt to be the case 
just previous to passing into the third stage. The duration 
of this stage is from a few hours to a week or more. 

3. The Stage of Depression. — As soon as this stage is fully 
entered upon, the senses become greatly blunted, and sopor 
sets in, which is followed by stupor and insensibility. The 
pulse is now feeble and irregular ; the eyes are turned in 
various directions, inward, outward, or downward ; the pupils 
are dilated, and the irides are more or less insensible to the 
stimulus of light. The eyelids are half closed, the cornea dim 
and blurred, and vision either double or otherwise perverted. 
The patient generally lies grasping and picking with the 
hands, moaning and groaning, with an irregular and feeble 
pulse, cool and somewhat moist skin, foul breath, and moist 
tongue. Paroxysmal flushes of the face sometimes occur, not- 
withstanding the great emaciation and debility. The alvine 
and urinary discharges are suppressed. The temperature is 
now almost always below the normal standard, especially in 
young subjects. Consciousness sometimes momentarily returns 
at the close of this period, but the patient soon relapses again 
into complete insensibility. The " hydrocephalic cry " is heard 
during this stage, but whether caused by pain or by reflex irri- 
tation is uncertain. Convulsions are such a marked feature as 



TUBERCULAR MENINGITIS. 183 

not unfrequently to occupy the greater portion of the period. 
The decubitus is on the back; and the duration of the stage 
is from one to two weeks. 

4. The Closing Stage. — This stage is characterized by paraly- 
sis, which is generally confined to the right side, and is usu- 
ally immediately preceded by convulsions. The head is drawn 
back, with great distortion of the face and limbs. The patient 
generally lies in a state of complete unconsciousness, but some- 
times raves. The face and head, on one side of the body, is 
usually drenched in sweat, while the other is cold and dry. 
The face is of a bluish or violaceous hue, the respiration hur- 
ried, and the breath cold. The pupils are almost always 
widely dilated, but occasionally they are contracted. The 
discharges are voided involuntarily, the urine being of a deep 
} 7 ellow color. The temperature generally sinks several degrees 
below the normal standard, but in some cases it gradually and 
steadily rises until it reaches 105° or 106° F. before the patient 
expires. The duration of this stage is from a few hours to one 
or two weeks, and that of the whole disease is from two to 
three weeks. 

Morbid Anatomy. — The characteristic anatomical feature 
of this disease is the presence in the pia mater of numerous 
miliary tubercles, or, as they are sometimes called, granules. 
These granulations are of a greyish or yellowish- white color, 
similar in appearance, and doubtless also in character, to those 
which occur in pulmonary miliary tuberculosis. They are 
located chiefly at the base of the brain, and it is only in a 
small proportion of cases that they occur to any considerable ex- 
tent elsewhere. They are generally very numerous along the 
course of the great vessels, especially in the fissure of Sylvius. 
There is also to be found in the subarachnoid space adjoining 
the blood-vessels, a jelly-like substance, similar to the exuda- 
tion which occurs in simple meningitis. The ventricles gen- 
erally contain from two to six ounces of turbid serum, and the 
fornix and adjacent tissues are often much softened, and are 
sometimes even diffluent. This softened tissue exhibits under 
the microscope the presence of numerous granulation corpus- 
cles. The substance of the brain is everywhere abnormally 



184 INTRACRANIAL DISEASES. 

vascular. The pia mater is always more or less inflamed, 
thickened by infiltration of plastic matter, and unduly adhe- 
rent to the cerebral surface. 

Pathology. — As before stated, miliary tubercles and tuber- 
cular deposits are generally present in these cases in other 
portions of the body, particularly in the lungs, bronchial 
glands, and peritonaeum, proving conclusively, I think, that 
acute hydrocephalus is nothing more nor less than a true 
tubercular form of meningitis. 

The granulations appear first at the base of the brain, 
probably in consequence of the greater vascularity, of that 
part of the organ. These adventitious deposits excite a com- 
mon inflammation in the neighboring tissues, and thus give 
rise to the morbid phenomena characteristic of the affection. 
These facts not only throw a flood of light upon the pathology 
of the disease, but are of the greatest consequence so far as 
the prognosis and treatment are concerned. 

Etiology. — While there can be no doubt of the fact that 
tubercular meningitis, instead of being an independent affec- 
tion, is but an expression of that general state of the system 
known as acute tuberculosis, there are nevertheless a number 
of determining causes that are worthy of consideration. 
Thus, age appears to be an important factor, since the disease 
occurs w r ith special frequency in children between the ages of 
two and seven, is less common between eight and ten, still less 
between ten and twenty, and is rarely met with beyond these 
extremes, though it has been known to occur in very young 
infants, and also in advanced life. In children it is apparently 
often inherited, while in adults it occurs generally as a com- 
plication in the course of chronic phthisis. Males appear to 
be more subject to the disease than females, and this is said 
to be the case at all ages. 

As to other exciting causes, although they probably exert 
but little if any independent influence upon the disease, yet, 
owing to the strong predisposition existing in these cases, and 
the constant irritation caused by the presence of foreign 
matter within the cranium, there is a constant tendency to 
relapse upon exposure to extremes of cold and heat, blows, 



TUBERCULAR MENINGITIS. 185 

falls, rapid jolting or exercise, the irritation produced by 
worms or teething, the repercussions of cutaneous eruptions, 
ordinary attacks of fever and inflammation, and in fact any- 
thing calculated to accelerate the circulation, or cause a deter- 
mination of blood to the brain. The same is true, also, of 
hygienic deficiencies, especially those which favor mal -nutri- 
tion, such as seclusion from air and sunlight, an insufficient 
quantity or a poor quality of food, or a diet that induces 
functional derangements of the digestive organs; to which 
may be added, neglect of cleanliness, improper or insufficient 
clothing, and, in the case of adults, unhealthy occupations. 

Diagnosis. — The importance of making an early and cor- 
rect diagnosis in these cases cannot be overestimated. Un- 
happily, this is often a very difficult thing to accomplish, 
especially in the earlier stages, as the symptoms of the first 
two stages of tubercular meningitis are frequently far from 
distinctive. It is true, the symptoms may be caused by the 
development of this disease, but, on the 'other hand, they 
may also represent simply some form of gastro-intestinal irri- 
tation, or at most the setting in of a specific fever. Under 
these circumstances, it is but natural to infer, that a careful 
examination of the general condition of the patient will 
materially assist in clearing up the diagnosis; but the fact is, 
this general condition sometimes only serves to still further 
complicate the case. For not only is it extremely difficult, 
at times, to recognize acute tuberclosis when it actually exists, 
but it not unfrequently happens that the state in question 
gives rise, not only to the same kind of constitutional symp- 
toms, but apparently to the same form of cerebral disturbance; 
and that, too, when, as the subsequent histor} 7 of the case may 
demonstrate, no tubercular meningitis is present. Such symp- 
toms, however, should always put us upon our guard ; and if 
the general condition of the patient and the history of the 
case are such as to establish the existence of acute tuberculosis, 
the cerebral symptoms may safely be regarded as an expres- 
sion of the meningeal affection. 

Trousseau insists upon the great importance of the so-called 
"tache cerebrale " as a diagnostic sign of tubercular menin- 



186 INTRACRANIAL DISEASES. 

gitis. This is a peculiar form of vaso-motor irritability ex- 
hibited when the nail of the finger, for example, is drawn 
across the abdomen or other portion of the body; in which 
case, if tubercular meningitis is present, a red line is almost 
certain to be slowly developed, and to remain a longtime. 
But as this symptom is sometimes met with in other diseases, 
Trousseau justly regards the irregularity of the respiration as 
a still more important diagnostic sign of tubercular menin- 
gitis; as in no other disease, he says, do we meet with this 
singular anomaly. If, then, along with these characteristic 
symptoms, together with those of the premonitory and initial 
stages above enumerated, the patient becomes more and more 
drowsy ; if the pulse falls much below the natural standard 
and at the same time becomes irregular ; if there is also a 
feverish condition existing, with but little if any thirst ; and 
especially if there is retraction of the abdomen and obstinate 
constipation present, we may safely conclude that tubercular 
meningitis is the only intracranial disease with which we have 
to do. 

Prognosis. — Whether complete and permanent recoveries 
ever take place after the disease is fully developed, may well 
be doubted. Although apparent recoveries have occasionally 
been reported, most authors regard all such cases as instances 
of mistaken diagnosis, believing it to be irrational to expect 
radical cures in cases where the cause cannot be removed. 
There is reason to believe, however, that such cures have, in 
some rare instances, been affected, especially under homoeo- 
pathic treatment; unless, indeed, we choose to regard such 
apparent recoveries as nothing more than a long and com- 
plete remission in the intensity of the symptoms. While, 
however, death is almost certain within three or four weeks 
from the full development of the disease, I am strongly in- 
clined to think, in common with some others, that, if taken in 
hand early and judiciously treated, the farther development of 
the disease may be prevented. But, of course, such a result 
cannot, from the very nature of the case, be counted upon with 
any degree of certainty ; and therefore the practitioner should 
be prepared to find his efforts in this direction, if not wholly 



TUBERCULAR MENINGITIS. 187 

thwarted, at least attended with but a very indifferent measure 
of success. 

Treatment. — It is evident from what has been said, that if 
any permanent good is to be accomplished in this disease by 
medical treatment, the case must be taken in hand at a com- 
paratively early period, before any well-marked organic 
changes have taken place in the diseased membrane. During 
the purely premonitory stage there is hope, as at that time 
the symptoms of irritation predominate ; and as the condition 
is one of simple hyperaemia, such remedies as Belladonna, 
Clna, Gelsemium, and Glonoin, are not only specially indicated, 
but are found to be highly serviceable in allaying the morbid 
action. Even at a later period, after the tubercular process 
has set in and the disorganizing metamorphosis is progress- 
ing, we have found good results to follow the administration 
of these and other indicated remedies, though of course the 
case will then need to be very closely watched and carefully 
treated. 

As regards hygienic measures, which should on no account 
be neglected, reference may be made to the therapeutic hints 
given under this head in the above section on etiology. 

General Indications. — Prodromic Stage. — Bell., Bry., Cham., 
Gels., Glon., Ign., Ipec, Puis., Yerat, vir. 

First Stage. — Aeon., Bell., Gels., Glon., Hyosc, Hell., Stram., 
Zinc. 

Second Stage. — Apis, Apoc, Artem., Bell., Cin., Dig., Hell., 
Hyosc, Merc, Stram. 

Third Stage. — Apis, Arg. nitr., Cupr., Ign., Indigo, Ipec, 
Mosch., Op., Plumb., Rhus tox., Sulph. 

General Condition. — Baryta carb., Calc carb., Calc phos., 
Lycop., Phos., Silic, Sulph. 

Special Indications. — In addition to the special indicaiions given 
under the heads of Simple Meningitis and Cerebral Hyper- 
emia (q. v.), the following closely-related remedies should 
receive particular attention : 

Baryta carb. — Glandular enlargements; stiffness of the neck; 



188 INTRACRANIAL DISEASES. 

eruption upon or behind the ears ; wasting of the flesh ; ver- 
tigo ; drowsiness ; stitches in the head, commencing immedi- 
ately on entering a warm room. This remedy is called for in 
all cases where the above symptoms show themselves, and 
especially if there are suspicious hereditary proclivities. 

Calcarea carb. — Lively, precocious, large-headed children, 
with tender constitutions, a swollen abdomen, and irregular 
bowels, which are inclined to looseness ; profuse perspiration 
about the head and neck during sleep ; child screams out 
unexpectedly or without cause. Especially suited to children 
of scrofulous habit, and as an intercurrent remedy. 

Calc. phos. — Children with retarded dentition, scrofulous, 
and greatly emaciated ; stools loose, green, and occasionally 
slimy ; child always wanting to nurse ; muscles shrunken and 
flabby ; slow in learning to walk ; craves potatoes and other 
forms of starchy food. This remedy is also suited to the 
scrofulous dyscrasia, especially when it threatens to run into 
acute tuberculosis, or is complicated therewith. 

Kali iod — This is Kafka's specific for this affection. He 
advises the remedy to be used early, before the tubercular exu- 
dation has taken place as well as afterward, the remedy having 
acted favorably at both periods. The special indications are : 
stinging, darting pains in the head, preventing sleep ; pain 
and heat in the head, with burning and redness of the face ; 
haemorrhage from the nose ; drowsiness ; dry and hacking- 
cough ; spasmodic contraction of the muscles; chilliness al- 
ternating with flashes of heat ; paralysis, especially when 
hemiplegia 

Lycopodium. — Somnolency, gradually deepening into coma ; 
convulsions, either partial or general ; child throws its head 
from side to side, moans, and screams out in sleep ; child 
sleeps with its eyes only half closed ; face pale and cold ; neck 
stiff; body greatly emaciated; bowels costive. This is a 
highly important remedy in this disease, on account of its 
relationship to anaemia and tuberculosis. 

Silicea. — Children with enlarged heads and slowly-closing 
fontanelles ; great drowsiness, with determination of blood to 
the head, especially when the head is low ; heat and redness 



TUBERCULAR MENINGITIS. 189 

of the face, with cold hands and feet ; disposition to sweat 
about the head and face ; sudden starting in sleep ; violent 
stitching headache ; sour eructations, frequently associated 
with nausea and vomiting ; obstinate constipation. 

Spongia. — This is Hering's great remedy for scrofulous and 
tuberculous subjects. The special indications are : Redness 
of face, with anxious expression of countenance ; determina- 
tion of blood to the head ; heat in the head ; bending of the 
head backwards ; face alternately red and pale ; eyes staring, 
lids wide open ; vision double. Child frequently wakes with 
a start ; muscular twitchings accompany the fever ; somno- 
lency and stupor. 



190 INTRACRANIAL DISEASES. 



CHAPTER III. 

TRAUMATIC MENINGITIS. 

There are three distinct forms of traumatic cerebral menin- 
gitis, namely: 1. pachymeningitis, in which the inflammation 
is limited chiefly to the external surface of the dura mater; 
2. arachnitis, in which the inflammatory process is confined 
to the arachnoid membrane; and 3. leptomeningitis, or, as it is 
sometimes called, subarachnoid meningitis, in which the pia 
mater and subarachnoidean areolar tissue are involved. 

1. Pachymeningitis. 

Traumatic cerebral pachymeningitis, or inflammation of the 
outer surface of the dura mater of the brain, is always a sur- 
gical disease. It is secondary to all those forms of head 
injuries by which the skull-bones are fractured or penetrated, 
such as gun-shot wounds, bayonet-thrusts, sabre-cuts, etc. In 
most cases the bone itself is contused and more or less of the 
pericranium about the wound separated. 

Symptoms. — For several days after the accident the patient 
appears to do well, and the surgeon, if inexperienced, is apt 
to imagine that, notwithstanding the severity of the wound, 
the parts have escaped serious injur}\ In the course of a 
week or ten days, however, the patient begins to suffer from 
pains in his head, loses his appetite, feels chilly, and becomes 
more or less restless and anxious. As these symptoms increase, 
the patient becomes dull and drowsy, and may sink into a 
state of stupor or insensibility. Other symptoms, also, may 
present themselves, such as rigors, delirium, convulsions, 
vomiting, constipation, coma, metastatic inflammation of the 



TRAUMATIC MENINGITIS. 191 

lungs and other organs; but most of these symptoms are due 
to the setting in of pyaemia, a condition which needs to be 
carefully distinguished from the meningitis itself. The py- 
aemia, which is a very common complication in these cases, 
is due, not to the pachymeningitis, but to inflammation of the 
bone, and this may be the cause of either, or of both, of the 
former diseases. If the diseased bone be examined, it will be 
found discolored, the diploe of a greenish color, and below it, 
probably, a small collection of pus. The pus itself is gener- 
ally discolored, and is surrounded by a layer of viscid lymph, 
which separates the membrane from the bone. In most cases, 
the inflammation extends to the arachnoid membrane, which 
is separated from the hemispheres by a layer of puro-lymph. 
This gives rise to other symptoms, the most important and 
characteristic of which is crossed hemiplegia. 

In interpreting the symptoms above given, we should re- 
member that rigors seldom occur in these cases except as a 
result of pyaemic infection, the decomposing material finding 
its way into the circulation through the veins of the diploe, 
which become inflamed in conjunction with the gangrenous 
osteitis. We may be quite certain that this is the case if the 
rigor be repeated. This complication is as common as it is 
fatal ; and even when pyaemia is not present, arachnitis 
general^ is, so that the surgeon has but little chance of 
saving his patient, whether he trephines him or not. 

Treatment. — As will be seen, these are purely surgical 
cases, and require surgical treatment. This, however, should 
be strictly homoeopathic, as well as preventive, in its character, 
for if either of the complications above mentioned should set 
in, recovery would be scarcely possible. Hence, after carefully 
cleaning the wound, if the surgeon finds that a depressed 
fracture is present, he should at once trephine, so as to prevent 
the supervention of meningitis, by elevating the depressed 
bone, removing the detached fragments, if any, and allowing 
a free escape of the secretions. He should then apply a dress- 
ing of charpie, or of borated cotton, saturated with Calendula 
lotion, and this should be kept diligently moistened. At the 
same time the indicated remedy should be given internally, 



192 INTRACRANIAL DISEASES! 

which in most cases will be either Aconite or Belladonna. 
This is far better than what is called the Lister's plan of 
treatment, which furnishes little or no protection against con- 
tagion, and scarcely ever succeeds in preventing inflammation, 
with all its direful consequences. 

2. Arachnitis. 

Although this form of traumatic meningitis is of common 
occurrence, Althaus denies the possibility of its existence as a 
distinct disease, on the grounds that Kolliker and other his- 
tologists have shown that the so-called parietal layer of the 
arachnoid does not exist, while inflammation of the visceral 
la} r er never occurs without simultaneous inflammation of the 
pia mater. But it is a sufficient answer to this reasoning to 
say, that the anatomical characters of arachnitis are unmis- 
takable, and that the distinction between this disease and in- 
flammation of the subarachnoidean areolar tissue and pia mater 
is easily made, especially upon post-mortem examination, as 
we shall presently show. 

Morbid Anatomy. — The leading anatomical peculiarity of 
arachnitis consists in this, that an even layer of purulent 
lymph covers the cerebral convolutions, but does not dip into 
the sulci, owing to the intervention of the arachnoid mem- 
brane; which stretches across instead of entering the cerebral 
depressions; but when, on the contrary, the subarachnoid 
spaces are involved, the sulci are filled with lymph, and the 
internal surface of the arachnoid remains free and unaffected. 

Symptoms. — The leading symptoms of acute diffuse arach- 
nitis are : more or less delirium, generally of a mild, wander- 
ing character, elevation of temperature, and hemiplegia; the 
latter attended by incontinence of fseces and urine, and occa- 
sionally by unilateral sweating. The hemiplegia, which is the 
most important and characteristic symptom, is seldom com- 
plete, its degree being proportionate to the extent of the 
arachnitis. In cases where the inflammation involves the 
membrane of both hemispheres, all the limbs are liable to be- 
come paretic, in which case the hemiplegia is not so easily 
distinguishable. 



TRAUMATIC MENINGITIS. 193 

Etiology. — Many cases of arachnitis result from compound 
fracture of the skull, with laceration of the dura mater. In 
these cases the arachnitis is secondary to osteitis. Sometimes 
the brain substance is also punctured, and then the case is 
liable to become complicated with diffuse encephalitis. As to 
the accompanying hemiplegia, it can hardly be due to the ef- 
fused fluid, for this is generally inconsiderable in quantity. 
Most likely it results from some change in the cortical sub- 
stance of the brain, as the latter is generally found to be more 
or less discolored, and of a greenish-grey appearance. 

Diagnosis. — We have already hinted at the fact that diffuse 
encephalitis may complicate the case, and thus obscure the 
symptoms. But as encephalitis is not likely to follow in these 
cases unless there has been a direct injury of the brain, if the 
evidences of arachnitis are widely diffused over one of the 
hemispheres, and at the same time accompanied by hemi- 
plegia of the opposite limbs, we may safely conclude that the 
case is one of true arachnitis. This inference may not, it is 
true, always turn out to be correct, but the exceptions, if such 
there be, are probably more apparent than real ; since it is 
only when, in consequence of the extreme illness of the 
patient, the hemiplegia should happen to be overlooked, that 
there would be any liability of making a mistake. It should 
be remembered, also, that the hemiplegia involves both sensa- 
tion and motion; although, as the hemiplegia is incomplete, 
the defect in sensation is liable to escape detection. In all 
well-marked cases, however, no such ambiguity exists. 

Prognosis. — The prognosis is of the gravest possible char- 
acter, since it is even doubtful whether recovery has ever oc- 
curred after the disease has once become fully established. 

Treatment. — As in cases of traumatic pachymeningitis, the 
chances of success will depend much more upon the prevention 
of the inflammation, than they will upon curing it after it has 
once become established ; hence measures.similar to those rec- 
ommended under that head (q. v.) should be adopted. After 
the inflammation has once set in, however, the chief reliance 
will have to be upon such remedies as Aeon., Apis, Ars., Bry., 
Kali iod., Merc, and Sulph. 
13 



194 INTRACRANIAL DISEASES. 



3. Leptomeningitis. 



Traumatic leptomeningitis is, as the name implies, a form of 
inflammation which involves primarily the areolar tissue of the 
subarachnoidean spaces, and, it may be, also the structure of 
the pia mater. It may follow any form of injury to the skull- 
bones which involves perforation or laceration of the visceral 
layer of the arachnoid ; but as its most common and interest- 
ing form is met with after fracture of the base of the skull, or 
through the petrous portion of the temporal bone, we shall 
confine our description of the disease to that class of cases. 

Symptoms. — The symptoms of basal subarachnoid inflam- 
mation are often very obscure, but the condition may be rea- 
sonably inferred to exist when, after an injury to the base of the 
skull, vague cerebral symptoms, such as complete insomnia, with 
mild delirium, but without paralysis, set in ; and especially so 
if these symptoms have been preceded by deafness, facial pa- 
ralysis, and bleeding from the ear — symptoms which denote 
fracture of the petrous portion of the temporal bone. Other 
important symptoms, such as optic neuritis, variations of tem- 
perature, etc., have not yet been clearly identified as belonging 
to this disease. Patients affected with traumatic leptomenin- 
gitis may die very quickly, but as a general rule they live sev- 
eral clays after the injury, and in some cases appear to make 
good recoveries. 

Morbid Anatomy. — The inflammatory process is generally 
principally confined to the subarachnoid spaces at the base of 
the brain and medulla oblongata. Serous lymph is found in- 
vesting these parts beneath the arachnoid membrane, and ad- 
hering closely to them, as well as to the nerve-roots springing 
from them. The lymph is closely bound down by the super- 
imposed layer of the arachnoid, which is itself perfectly trans- 
parent and unaffected. The lymph cannot be wiped away, or 
otherwise removed, unless the arachnoid membrane is either 
lacerated or cut, proving conclusively that it is situated be- 
neath it. 

Pathology. — It is probable that the inflammation gains ac- 
cess to the subarachnoid spaces, by traveling along the trunks 



TRAUMATIC MENINGITIS. 195 

of the seventh nerve, affecting first the parts adjacent to the 
roots of this'nerve, and afterwards spreading upwards through 
the posterior fissures to the ventricles, or over the surface of the 
hemispheres, or else downwards on the medulla oblongata and 
its adnexa. 

One of the peculiarities of this form of meningitis is, that 
the fracture associated with it, instead of being a simple one, 
as it appears, is actually compound, air reaching the sub- 
arachnoidean spaces through the fracture, either by the way 
of the external meatus or the Eustachian tube. Whether the 
inflammation of the subarachnoidean areolar tissue ever 
results from this admission of air or not, is a question which 
we have no means of deciding. It is highly probable, how- 
ever, that such is the fact, as we know that the admission of 
atmospheric air into wounds, and especially into suppurating 
cavities, is not only highly prejudicial, but determines to a 
great extent the character of the inflammation. 

Prognosis. — The most that can be positively asserted under 
this head is, that while man} T of those that recover from frac- 
tured base are doubtless cases of simple though severe contu- 
sion, others, especially those attended by the above symptoms, 
and in which more or less serous fluid has escaped from the 
ear, are probably cases of basal meningitis. Such recoveries 
are, of course, very rare ; so rare, indeed, as to call for an un- 
favorable prognosis in all cases. 

Treatment. — There is nothing peculiar about the treat- 
ment of these cases, the symptoms in every instance clearly 
pointing out the appropriate remedies. Hence, in addition to 
the necessary surgical measures, should any be required, the 
practitioner will do well to study the special indications given 
under the head of Simple Cerebral Meningitis (q. v-). 



196 INTRACRANIAL DISEASES. 



CHAPTER IV. 

CHRONIC MENINGITIS. 

Chronic cerebral meningitis may be most conveniently 
and profitably considered under two heads, according as it 
involves either the membranes of the convexity, constituting 
what we shall call Chronic Convexital Meningitis, or as it affects 
the membranes at the base of the brain, generally known as 
Chronic Basal Meningitis. 

1. Chronic Convexital Meningitis. 

This is sometimes the sequela of the acute form of the dis- 
ease, but more frequently it comes on without a previous 
acute attack. 

Symptoms. — The symptoms of chronic convexital menin- 
gitis resemble for the most part those belonging to the disease 
commonly known as general paralysis of the insane ; * they 
also resemble to some extent those produced by softening of 
the convexity. When, however, the disease follows an acute 
attack of meningitis, the symptoms are similar to those of 
that affection, but are less violent, and pursue a much less 
rapid course. Generally the first symptom to attract the at- 
tention of the patient is headache. The pain, which though 
persistent is not very intense, is usually situated either in the 
forehead or at the top of the head. It is aggravated by heat, 
by mental exertion, and by bending the head forward. More 
or less vertigo and drowsiness are also generally present in 
these cases. But the leading feature of the disease is paralysis, 
which may show itself by impaired articulation, trembling of 

* See " Nervous Diseases," p. 173. 



CHRONIC MENINGITIS. 197 

the muscles, weakness of the limbs, paralysis of the lower 
sphincters, defective memory, and a general impairment of 
mental vigor. Muscular spasms, involving both single muscles 
and groups, are not uncommon ; and occasionally there are 
epileptic and epileptiform convulsions. 

Hemiplegia, involving one whole side of the body, may set 
in, or the paralysis may affect only a single limb, or a partic- 
ular group of muscles. The ocular muscles generally escape 
altogether, and so do the special senses, with the exception of 
general sensibility, which is usually more or less elevated or 
depressed. Thus, there may be either local or general anaes- 
thesia ; or there may be hyperesthesia of the skin and of the 
sensory nerves generally, giving rise to neuralgic pains in 
various parts of the body. 

The mental faculties, though weakened, are not, as a rule, 
greatly disturbed, unless the cortical substance of the brain is 
also involved in the inflammation, and then we have the dis- 
ease known as general paralysis of the insane. 

In these cases, and also when the disease follows an acute 
attack, or when it is subacute, the symptoms are more vio- 
lent, being attended by more or less delirium, vomiting, scanty 
and high-colored urine, constipation, defective vision, convul- 
sions, paralysis, coma, and even death. Such cases, however, 
can scarcely be regarded as cases of simple chronic meningitis, 
although described as such by many of the older authors, but 
rather as a complication of the disease with cortical inflamma- 
tion of the brain, such as is met with in some cases of chronic 
mania, and also in general paralysis. 

Morbid Anatomy and Pathology. — Although the thick- 
ening and opacity of the arachnoid, so frequently met with in 
chronic cerebral diseases, and which was formerly regarded as 
due to chronic inflammation, is now looked upon by many as 
a mere result of degenerative overgrowth — the consequence, 
chiefly, of frequent and long-continued congestions — there can 
be but little doubt, I think, that, as a general rule, the condi- 
tion in question does result from chronic inflammation, rather 
than from simple irritation or congestion. For, in addition 
to the hyperemia and thickening, we have, in the majority of 



198 INTRACRANIAL DISEASES. 

cases, adhesions of the membranes to each other and to the 
cerebrum, as well as deposits of exudation on the surface of 
the brain which are distinct from the alterations of the mem- 
branes. Thus we may have, not only injection, opacity, and 
thickening of the membranes, but serous and gelatiform ex- 
udatious beneath the arachnoid, discolored fluids and puriform 
matter in the same situation, and adherent and non-adherent 
false membranes. Syphilitic gummata and tubercular gran- 
ules are also sometimes found in the membranes of the con- 
vexity, but these neoplasmata are much more common in 
the membranes at the base. 

Causes. — There are numerous causes capable of exciting 
chronic convexital meningitis, though many cases occur in 
which the etiology is more or less obscure. It is generally 
admitted that the disease is sometimes the result of an acute 
attack of convexital meningitis. It may also originate in the 
same way as the acute affection, namely, by prolonged expos- 
ure to extreme heat, both natural and artificial, by blows and 
falls upon the head, and by the excessive use of alcoholic 
liquors. It may also be caused by any severe mental strain, 
especially when long continued. Cerebral syphilis and tuber- 
culosis are likewise occasional causes, but when produced by 
the last-named condition, it should not be confounded with 
acute hydrocephalus, which is an entirely different affection. 

Diagnosis. — The comparative mildness of the symptoms, 
as well as the chronicity of its course, will serve to distinguish 
the disease from the acute form of the affection ; and when 
originating in the latter, the previous history of the case will 
be sufficient to establish its true nature. The case is different, 
however, when we come to compare the symptoms of this dis- 
ease with those of inflammation and softening of the cortex, 
and particularly when the two diseases are combined, as the 
symptoms of the two conditions are almost identical. Here 
the intensity of the symptoms, and the nature of the cause 
producing them, are about the only means we have of differ- 
entiating between them. Thus, while the pain is less in soften- 
ing than it is in inflammation of the membranes, the mental 
symptoms are more severe, and vice versa. 



CHRONIC MENINGITIS. 199 

Prognosis. — The prognosis, as in every other form of cere- 
bral inflammation, is unfavorable. The only exception is 
where the disease is of a syphilitic nature, in which case the 
chances of recovery are good, provided the case is taken in 
hand early and properly treated. Non-syphilitic cases, how- 
ever, are not always fatal, as is proved by the fact that post- 
mortem appearances have established the previous existence 
of the disease in individuals who have died of other affections. 

Treatment. — The treatment of chronic convexital menin- 
gitis differs in no essential respect from that of the acute form 
already given under the head of Simple Meningitis (q. v.). 
Should there be reason, however, to suspect the existence of a 
tubercular complication, or if there are evidences of any form 
of tuberculosis, the practitioner should not fail to consult the 
indications given under the head of Tubercular Meningitis. 
Syphilitic cases will, of course, demand anti-syphilitic treat- 
ment; and whenever the dyscrasia can be satisfactorily made 
out, the practitioner can pretty safely rely on Kaliiodatum and 
Mercurius corr. as being effective remedies in the case. 

2. Chronic Basilar Meningitis. 

Those cases of chronic basilar meningitis which result from 
injuries, have already been considered under the head of 
Traumatic Leptomeningitis (q. v.). 

Symptoms. — Tonic and clonic spasms, affecting the muscles 
of the neck and limbs, are generally among the earliest 
symptoms of the disease. Sometimes the patient is seized at 
the outset with general convulsions of an epileptiform char- 
acter, but without losing consciousness. At others, the spas- 
modic action is confined to particular muscles or sets of 
muscles, especially those of the upper extremity. 

Pain is also a prominent symptom, and sometimes it is 
about the only one that attracts the attention of the patient. 
It is generally located in some part of the head or face, and is 
remarkable both for its intensity and its obstinacy. Vertigo 
is another marked symptom, and is so great in some cases as 
to compel the patient to constantly maintain the recumbent 
position. 



200 INTRACRANIAL DISEASES. 

But the most important symptom belonging to these cases 
is paralysis. As the disease is seated at the base of the brain, 
the paralysis may implicate any of the parts supplied by the 
motor branches of either of the cranial nerves. This gives 
rise to a great variety of symptoms, according to the particular 
nerves affected. Thus, if the seventh cranial nerve be impli- 
cated, we shall not only have facial paralysis, but we are also 
liable to have more or less impairment of articulation and 
deglutition, in consequence of the paralysis involving some of 
its branches of communication with other nerves. If the third 
be involved, then there may be paralysis of the levator palpe- 
brse muscle, causing a dropping of the upper lid; or there may 
be external strabismus and double vision, owing to paralysis 
of the internal rectus muscle ; or, if the implication of the 
nerve is incomplete, there may be simple dilatation of the 
pupil, with or without deficient accommodative power. In 
this case, also, the vision is more or less injured, owing chiefly 
to paralysis of the ciliary muscle, and consequent weakness of 
the accommodation. Defective vision may also result from an 
extension of the morbid process from the affected membrane 
to the optic nerve, giving rise to hyperemia of the optic nerve 
and retina, and even to optic neuritis, in which case vision 
may be entirely lost. The sense of hearing may also be 
greatly impaired, or even lost, by the auditory nerve becoming 
implicated in the inflammation. 

Anaesthesia is common, and this symptom may exist either 
with or without paralysis. The anaesthesia may be limited to 
a small portion of the surface of the body, as the face, trunk, 
upper or lower extremities, or it may involve the whole of one 
side. 

The mind is not usually affected to any considerable extent, 
at least at the outset, nor, indeed, so long as the inflammation 
is strictly limited to the basilar membranes. It is only when 
the inflammatory process involves more or less of the mem- 
branes of the convexity that the mental faculties are apt to 
suffer any permanent weakness or derangement. 

Morbid Anatomy. — The anatomical changes met with in 
chronic basilar meningitis, do not differ in their nature from 



CHRONIC MENINGITIS. 201 

those we have already described as belonging to the convexital 
form. The only peculiarity worthy of note, is the fact that 
here the morbid changes are generally much more limited in 
extent than they are in the former situation, the altered patches 
being sometimes less than half an inch in diameter. Syphi- 
litic and tubercular deposits are more common in this position 
than they are in the membranes of the convexity, probably for 
the same reason that the inflammatory process itself is more 
frequent in this portion of the cerebral membranes. 

Pathology. — It is only necessary to bear in mind the dis- 
tribution of the cranial nerves, in order to correctly interpret 
the symptoms arising from one or another of them becoming 
involved in the inflammatory process. The disturbances thus 
produced furnish us a ready means of determining, in most 
instances, the precise seat of the disease ; and this is still fur- 
ther facilitated by the circumscribed character of the inflam- 
mation. It is only, however, when the inflammatory process 
affects the substance of the brain itself, that the functions of 
motility and sensibility are disturbed in the trunk and limbs. 
Aphasia points to the third left frontal convolution of the 
brain, the morbid process reaching it through the fissure of 
Sylvius. Whenever, as not unfrequently happens, there is an 
alteration in the locality of the symptoms, the change indicates 
a transference or extension of the disease to a new region. 
Thus, the disease has been known to involve the third, fourth, 
fifth, sixth, and seventh nerves, in regular succession. 

Causes. — Hammond* regards syphilis as the most common 
cause of chronic basilar meningitis; next, the abuse of alco- 
holic liquors ; and next, excessive emotional disturbance. 
According to my experience, however, alcoholic beverages 
take the first rank in this disease as causative agents, though 
this may not be the case in our metropolitan cities, where 
syphilis is of comparatively greater prevalence. This disease 
has also been known to follow blows upon the head, atmos- 
pheric changes, and certain diseases, especially scarlet fever, 
diphtheria, suppurative otitis, and epidemic cerebro-spinal 
meningitis. 

* Loc. cit. 



202 INTRACRANIAL DISEASES. 

Diagnosis. — This disease is not liable to be mistaken for 
any other affection of the brain, provided sufficient attention 
is given to the history of the case, and the extent and charac- 
ter of the symptoms. This is not the case, however, with 
thrombosis of the arteries at the base of the brain, the symp- 
toms of which are scarcely distinguishable from those of 
chronic basilar meningitis. Generally, the best clue in these 
cases is the exciting cause, which, in connection with the his- 
tory of the case, may be sufficient for all practicable purposes, 
since the treatment of thrombosis is not likely to be followed 
with any permanently good results. 

Prognosis. — The prognosis of simple chronic basilar men- 
ingitis is more or less favorable or otherwise, according to the 
nature of the cause. When produced by syphilis, the disease, 
if promptly and correctly treated, may almost always be sub- 
dued. The same is true when the disease is due to severe 
moral perturbations, anxiety, or too close confinement to busi- 
ness, provided the patient can* be induced to submit to the 
requisite hygienic treatment. On the other hand, those cases 
which result from the abuse of alcoholic stimulants, as well as 
those which supervene upon purulent otitis, diphtheria, and 
epidemic cerebro-spinal meningitis, are generally fatal. 

Treatment. — The therapeutic measures already laid down 
in previous articles for the treatment of various forms of men- 
ingitis (q. v.), furnish all the directions and indications neces- 
sary for the successful management of every curable case of 
this disease, and therefore need not be repeated here. As for 
the resulting paralysis, we have the following 

General and Special Indications. — For Paralysis of the Facial 
Muscles. — Bar., Bell., Cadm., Caust., Cocc, Gels., Kali chlo., 
Nux vom., Op., Strain. 

For Paralysis of the Tongue and Organs of Speech. — Bar., Bell., 
Cocc, Dulc, Gels. 

For Paralysis of the Muscles of the Eye. — Argentum nitricum.— 
Weakness or paralysis of the ciliary muscles. 

Causticum. — Paralysis of any or all of the ocular muscles, 
especially when resulting from exposure to cold. 



CHRONIC MENINGITIS. 203 

Cuprum acet. — Paralysis of the nervus abducentis. 

Euphrasia. — Paralysis of the oculomotor nerve, especially 
when caused by cold, or a catarrhal condition of the eye exists 
at the same time. 

Gelsemium. — Paralysis of the oculo-motor and abducens 
nerves, or when it gives rise to double vision. 

Kali iod. — When the paralysis is of a syphilitic origin. 

Mercurius. — Same indication as for Kali iod. 

Nux vom. — When aggravated by the use of tobacco or 
stimulants. 

Opium. — Paralysis of the ciliary muscle. 

Paris quad. — Paralysis of the iris and ciliary muscle, espe- 
cially when there is pain in the eyes as if they were being 
pulled into the head. 

Phosphorus. — Paralysis associated with weakness of the sex- 
ual organs, and especially with spermatorrhoea, 

Rhus tox. — When resulting from exposure to cold and damp, 
or from changes in the weather. 

Senega. — Weakness of the superior rectus or superior oblique, 
in which the diplopia is relieved by bending the head forward. 

Spigelia. — When the paralysis is associated with sharp stab- 
bing pains through the head. 

Stramonium. — Paralysis from brain troubles, or when asso- 
ciated with facial paralysis. 



204 INTRACRANIAL DISEASES. 



CHAPTER V. 

EPIDEMIC MENINGITIS. 

Syx. : Cerebrospinal Meningitis. 

This is an epidemic, acute, diffusive inflammation of the 
membranes of the brain and spinal cord, resulting in a de- 
posit of puro-lymph upon the surface of the arachnoid, and 
an effusion of serum into the ventricles and subarachnoid 
space. 

Symptoms. — The attack, which is usually very sudden, is 
generally ushered in by vomiting, faintness, and severe head- 
ache; the latter being especially marked in the back of the 
head and neck. In many cases there are distinct chills, fol- 
lowed speedily by fever; but as a general rule reaction does 
not occur until a later period, being preceded by cold extremi- 
ties, insensibility, and sometimes convulsions. These symp- 
toms are followed by tonic spasms of all the extensor muscles 
of the limbs. 

If the patient survive this state of collapse, which is not 
always the case, he complains of severe pains in the back of 
the head and neck and along the spine ; and as these symp- 
toms increase in severity, the tonic rigidity becomes more 
and more developed, until opisthotonos, and a general tetanic 
condition, is induced. Accompanying this muscular spasm 
is a hypereesthetic state of the skin ; and neuralgic pains also 
appear in different parts of the body. 

On or about the second day of the disease, and sometimes at 
an earlier period, there generally appear upon the surface, 
in severe cases, irregular purplish spots, varying in size from 
a pin's head to large patches. The eruption usually shows 
itself first upon the lower extremities, and feels like small, 



EPIDEMIC MENINGITIS. 205 

hard pebbles under the skin. In some cases the eruption is 
entirely absent, or is confined to only a small area; in others, 
it becomes so general as to cover nearly the whole surface of 
the body. In addition to this characteristic eruption, which 
has conferred upon the disease the popular name of spotted 
fever, other skin eruptions frequently make their appearance, 
such as herpes, ecthyma, and pemphigus; the latter being 
confined, for the the most part, to the advanced stages of the 
malady. The vesicular eruptions, which are as common in 
mild as in severe cases, are most frequent on the face, neck, 
and shoulders. 

Both the temperature and the pulse are very irregular. 
The former generally rises from 100° F. to about 104° F., but 
is subject to very marked variations above and below these 
points; whilst not unfrequently it remains for a considerable 
period nearly at the normal standard, without any abatement 
of the other symptoms. On the other hand, as already stated, 
the temperature sometimes never rises, the patient dying in a 
state of collapse. The pulse, which does not always correspond 
to the temperature, generally rises to about 120, and has a 
peculiar jerking character. It is very irregular, sometimes 
varying twenty, thirty, and even forty beats within a few 
hours. 

The symptoms taken as a whole are decidedly typhoid from 
the beginning. The tongue, which at first is heavily coated and 
moist, generally becomes black, dry, and sometimes cracked, 
by the fourth or fifth day of the disease, especially in comatose 
cases. The stools are sometimes loose and offensive, and at 
others the reverse. In unfavorable cases, the stupor deepens 
into coma, faeces and urine pass off involuntarily, the vital 
powers become more and more depressed, and finally death 
closes the scene. In favorable cases, on the other hand, the 
sjunptoms are generally less severe, especially those of depres- 
sion, which are not only milder but less permanent, and in 
some cases do not appear at all ; the remaining symptoms 
gradually abate, and convalescence begins in from one to three 
weeks from the commencement of the disease. 

Complications and Sequelae. — Of those belonging to the 



206 INTRACRANIAL DISEASES. 

nervous system, paralysis is the most frequent, and is gen- 
erally confined to one of the upper extremities. The eye is 
often irreparably injured by the setting in of a low form of 
purulent opthalmitis, attacking either a part or the whole of 
the organ, and generally resulting in its entire destruction. 
In other cases the inflammation is limited to the cornea or 
iris, which, though not destroying the organs, may neverthe- 
less permanently impair the sight. The sense of hearing is 
not often destroyed, but a few cases of permanent deafness 
have been met with, doubtless arising from injury to the audi- 
tory nerve, the external origin of which is frequently im- 
bedded, so to speak, in the fibroid deposit on the surface of the 
medulla. Haemorrhages are not uncommon, especially in 
malignant cases. These generally occur from the nose, bow- 
els, kidneys, and uterus ; sometimes, also, from the ears. 
Acute inflammation, terminating in purulent effusion, some- 
times attacks the larger joints, and is a frequent complication 
in some epidemics. Chronic meningitis, with its train of se- 
quelae, has also been observed in these cases. 

Morbid Anatomy. — The most marked and characteristic 
alteration met with in epidemic meninigitis, is the yellowish- 
white or greenish-yellow deposit of puro-lymph found at the 
base of the brain. This deposit, however, is not confined to 
the base, but in fatal cases is also met with on the convexity, 
along the sulci, in the fissure of Sylvius, between the chiasma 
and pons, on the pons and cerebellum, and on the posterior 
surface of the cord. Serum is found in the ventricles and 
subarachnoid space ; the cerebral membranes are all more or 
less injected ; and the arachnoid is not only extremely vascu- 
lar, but is rendered opaque by the puruloid deposits before 
mentioned, w 7 hich vary in consistence from a thin, milk-like 
lymph to thick and dense fibrino- purulent deposits. The 
brain substance itself is more or less injected, and sometimes 
small spots of secondary softening occur, but in other respects 
the organ generally exhibits a normal appearance. 

Pathology. — Epidemic meningitis is an infectious disease, 
but what the real nature of the infective element consists in, 
is unknown. It has, like all other so-called zymotic diseases, 



EPIDEMIC MENINGITIS. 207 

been attributed to certain disease-germs introduced into the 
system from without, and more especially through the several 
mediums of the air, the water, and unwholesome food ; but 
as yet nothing definite has been discovered in these directions. 
Admitting that it is produced or propagated by a disease- 
germ, it appears to nourish best in damp, overcrowded, and 
badly ventilated habitations, in camps, jails, and other un- 
healthy situations ; yet it is not confined to such localities, nor 
to the lower walks of life. Besides, there is no known reason 
why it has such a special affinity for the central nervous sys- 
tem. The mystery doubtless belongs to the same category 
that determines the chief pathological changes of diphtheria 
to the mucous membrane of the fauces and neighboring parts, 
of variola and other allied diseases to the skin, and of syphilis 
to the periostial and other tissues. 

Causes. — Age appears to be an important factor in these 
cases, as the disease is most common during early life. It is 
especially frequent just before the period of adolescence, is 
not uncommon in early childhood, but is seldom met with 
after thirty-five or forty years of age. Sex also seems to have 
considerable influence, the disease being much more common 
in males than females. Whether occupation is a predisposing 
or exciting cause of the malady is not definitely known. The 
disease frequently appears among young army recruits, but 
this is probably due more to the sanitary surroundings than 
to the occupation itself. Physical exhaustion, however, in 
whatever way induced, is undoubtedly a predisposing cause. 
The disease appears more frequently in winter and spring 
than it does in hot weather; and in cold and temperate 
climates rather than in the tropical regions. Its epidemic 
and infectious nature has already been considered. 

Diagnosis. — The disease is liable to be confounded with 
typhus fever, purpura haemorrhagica, and malignant scarli- 
tina. It may be distinguished from ordinary typhus by the 
nervous symptoms, and by the sudden appearance of the 
characteristic rash, which is not preceded by petechise. Pur- 
pura haeniorrhagica is not attended by such high constitu- 
tional disturbances, nor by the peculiar nervous symptoms 



208 INTRACRANIAL DISEASES. 

which characterize epidemic meningitis. Malignant scarlet 
fever may generally be distinguished by the rash, sore throat, 
and nervous symptoms, as well as by the prevailing character 
of the epidemic ; but when the two diseases prevail together, 
the diagnosis will often be extremely difficult. 

Prognosis. — The prognosis varies greatly in different cases, 
depending chiefly upon the grade or intensity of the s} 7 mp- 
toms. When very mild, the disease usually terminates in 
recovery within two or three weeks. On the other hand, very 
severe cases, occurring suddenly, and accompanied by great 
depression of the vital powers, the characteristic eruption, 
haemorrhage, and coma, generally terminate fatally within a 
few hours, or at farthest within two or three days. Cases of 
medium severity, however, though often protracted, usually 
recover under homoeopathic treatment, the duration of the 
disease being from two to six or eight weeks. Occasionally a 
case assumes the chronic form, but in these instances the 
patient generall} r sinks into a state of marasmus, and dies in 
the course of a few months. The disease is most fatal about 
the age of puberty, probably for the same reason that it is 
most frequently met with at this period of life. The mortality 
in different countries varies from about forty to eighty per 
cent., and averages about sixty per cent., being highest, it 
is said,* among the Irish constabulary. 

Treatment. — Ice to the head and spine often has the effect 
of allaying the pain, but there is no evidence of its having 
been of any permanent benefit to the patient. Other local 
applications are equally valueless ; and the practitioner will 
succeed best by confining himself strictly to the homoeopathic 
treatment, as given in the following 

Special Indications. — Aconite.— In cases where there is well- 
marked reactionary fever, attended by chilliness, thirst, rest- 
lessness, dryness of the skin, and anxiety of mind. 

Agaricus. — Drawing pains in the back of the head ; violent 
pains all along the spine; stiffness and soreness of the nape of 

* Dr. Grimshaw in Quain's Die. of Med., p. 228. 



EPIDEMIC MENINGITIS. 209 

the neck and spine ; great weight in the forehead and temples, 
with delirium and coma. 

Apis mel. — Burning and throbbing in the head, with pain 
and stiffness in the back of the neck ; great prostration, both 
physical and mental ; brain feels tired ; stabbing pains in the 
occiput; swelling of the face, giving it an cedematous appear- 
ance ; hypersethesia of the skin, with stinging pains all over 
the surface; sense of suffocation, with great oppression of 
breathing; dulness of vision; urine scanty or suppressed; 
pulse variable and intermitting. 

Argentum nitr. — Intense headache ; vertigo ; photophobia ; 
ringing in the ears ; chilliness ; clouds before the eyes ; diplo- 
pia ; deafness ; cutting pains extending from occiput to fore- 
head, increasing and diminishing frequently ; face pale and 
emaciated; tongue coated white, or else black, hard, and dry; 
sordes upon the teeth ; lips and nails blue ; breathing greatly 
oppressed ; incontinence of faeces and urine ; jerking and 
trembling of the limbs ; epileptiform convulsions. 

Arnica. — Great general prostration, with a sore, bruised feel- 
ing everywhere ; back of the neck extremely sensitive to the 
touch ; diuresis ; formication and cramps in the extremities. 

Arsenicum. — Great restlessness and prostration ; the char- 
acteristic thirst for but little water frequently repeated ; tongue 
dry and trembling ; stiff, sore feeling in the back of the neck ; 
scalp sensitive and painful ; vertigo, with humming in the 
ears ; face pale and corpse-like ; dulness of vision ; diarrhoea; 
anxious respiration ; tetanic rigidity ; spasmodic grinding of 
the teeth ; comatose state. 

Baptisia. — Typhoid symptoms, accompanied by a bruised 
and painful feeling in the back of the head and neck ; wan- 
dering pains in all the limbs ; body feels universally stiff and 
sore ; great restlessness, especially of the head and limbs, which 
are in constant motion ; dark, livid spots on the skin ; consti- 
pation; stomach sore and sensitive to pressure; vertigo; weak- 
ness and trembling of the limbs. 

Belladonna. — Violent, stupefying headache, worse in the back 
of the head, and extending to the neck ; ameliorated by bend- 
ing the head backward ; convulsive movements, especially of 
the muscles of the face and neck ; grinding of the teeth ; 
14 



210 INTRACRANIAL DISEASES. 

hyperesthesia of the senses ; upper part of the body hot, 
extremities cold; retention or inconstancy of the urine; pupils 
dilated ; coma, either with or without delirium. 

Bryonia. — Intense headache, with stiffness of the neck, and 
great pain and soreness in all the limbs and joints; symptoms 
greatly aggravated by motion. 

Camphor. — Throbbing pain in the back of the head, w T hich 
is drawn backwards or to one side ; death-like paleness of the 
face ; tetanic spasms ; violent cramps in the stomach and 
limbs ; general surface of the body blue and cold ; cold, 
clammy perspiration ; great oppression of the chest, with diffi- 
cult breathing ; no reaction from the initiatory chills. 

Cannabis ind. — Vertigo on rising, with stunning pain in the 
back of the head ; pain across the shoulders and spine ; fixed, 
staring eyes, with dilated pupils ; hearing acute ; face cold, 
with drowsy and stupid expression of countenance ; great 
oppression of the chest ; convulsions ; emprosthotonos or opis- 
thotonos, with loss of consciousness ; collapse, with pale, 
clammy, and insensible skin ; pulse feeble and irregular. 

Cantharides. — Violent, lancinating pains in the occiput, 
extending deep into the head ; priapism, with amorous 
frenzy ; eyes staring, or dull and sunken ; face pale, with ter- 
ror-stricken expression of countenance ; spasmodic constric- 
tion of the throat; retention and suppression of urine; tetanic 
spasms ; fainting, trembling, and general coldness. 

Chininum. — Violent throbbing headache, with vertigo, heat 
in the face, and extreme weakness ; symptoms intermitting. 

Cicuta. — Head retracted; muscles of the neck sore and stiff; 
vertigo, with moaning delirium ; anxious expression of coun- 
tenance ; double vision ; dilated pupils ; spasmodic action of 
the muscles of the face and limbs ; tonic contraction of the 
cervical muscles ; opisthotonos ; convulsions, attended with 
cries, working of the jaws, distortion of the limbs, painful dis- 
tention of the abdomen, and spasm of the muscles of the chest, 
followed by insensibility and immobility; general paralysis; 
diarrhoea or constipation ; ashy hue of the skin ; pain in the 
stomach with vomiting. 

Cimicifuga. — General headache, but not very violent, except 
it may be in the vertex and occiput; pain in the neck, shoul- 



EPIDEMIC MENINGITIS. 211 

ders, and spine ; low, restless, excitable delirium, like that of 
delirium tremens ; eyes painful and sensitive to pressure ; 
pupils dilated ; general prostration, accompanied by more or 
less nausea and vomiting ; profuse cold sweat all over the 
body, with very quick pulse ; tongue swollen and throat dry, 
causing a constant desire to swallow ; muscular twitchings in 
various parts of the body. 

Cocculus. — Severe headache, with vertigo, vomiting, and 
feeling as if the eyes would be torn out; face pale and bloated; 
painful' stiffness of the muscles of the neck ; convulsive trem- 
bling of the head ; epileptiform convulsions ; constriction of 
the chest, with heavy and laborious respiration ; fainting fits ; 
miliary eruptions. 

Orotalus. — Extremely violent headache ; pains in all the 
limbs ; staring eyes, with delirium ; burning, unquenchable 
thirst ; nausea and vomiting, preceded or accompanied by 
faintness ; anxious breathing ; purplish spots on the skin ; 
diarrhoea, with faintness ; pallid face ; painful heaviness of 
the limbs ; feeble pulse. 

Cuprum. — Convulsive symptoms predominate ; nausea and 
vomiting from cerebral congestion ; nervous trembling, with 
hyperesthesia of the senses ; sad, depressed features, with dim, 
lustreless, sunken eyes, surrounded with blue rings ; somno- 
lency or coma ; general paralysis. 

Digitalis. — Sharp stitches and severe cutting pains in the 
nape of the neck ; stiffness in the back and side of the neck ; 
violent, lancinating pains in the head, especially in the occiput; 
head tends to fall backward when sitting or walking; delirium 
resembling that of delirium tremens; heart's action slow, irreg- 
ular, and labored ; depression, accompanied by faintness and 
vomiting ; convulsions, with retraction of the head ; syncope, 
with coldness and tendency to collapse. 

Gelsemium. — Severe chill, followed by cerebral and spinal 
congestion ; great depression, with dilated pupils, livid cheeks, 
dulness of speech, icy coldness of hands and feet, extreme 
weakness, very weak pulse, and laborious respiration ; nausea 
and vomiting ; general muscular paresis, without any impair- 
ment of the mental power ; somnolency and coma ; sweating 
relieves. 



212 INTRACRANIAL DISEASES. 

Glonoin. — Violent, throbbing headache, accompanied by a 
bursting sensation ; face pale, or else deeply congested ; blind- 
ness, with nausea and faintness ; pain throughout the central 
nervous system ; labored action of the heart. 

Hydrocyanic acid. — Malignant cases, attended with imme- 
diate collapse ; protruded, half-open eyes ; dilated and station- 
ary pupils ; blindness ; bloated and bluish face ; tongue pro- 
truded and paralyzed ; general coldness ; feeble, irregular 
pulse and respiration ; incontinency of faeces and urine. 

Hyoscyamus. — Violent headache, alternating with pains in 
the back of the neck ; throbbing sensation in the brain ; draw- 
ing in the nape when turning the head ; heaviness of the head, 
with dimness of vision, palsy of the tongue, and small, inter- 
mitting, and quick pulse; convulsions, with spasms of the 
chest, and temporary arrest of breathing ; stiffness of cervical 
muscles and trismus ; constant grinding of the teeth ; epilep- 
tiform convulsions ; jerking of the limbs ; brown spots and 
large pustules on the skin, also gangrenous vesicles ; involun- 
tary stool and urine. 

Lycopodium. — Congestive headache, with pain extending 
down the neck ; hyperesthesia of the special senses ; oppres- 
sion of the chest, with fan-like movement of the nostrils; sense 
of constriction in the chest and abdomen, as though bound 
with a hoop ; melancholy and irritable ; dreads solitude ; 
numbness and twitching of the limbs. 

Nux vom. — Hyperesthesia of the cerebro-spinal system of 
nerves ; shocks in the brain ; scalp sensitive to the touch ; 
loud, reverberating sounds in the ear; oversensitive to odors; 
stitches through the body ; conscious opisthotonos ; convul- 
sions renewed by the least touch ; numbness and paralytic 
drawing in the limbs ; bruised sensation in the head, limbs, 
and body, with feeling of heaviness. 

Opium. — Stupor, or tendency thereto, with or without de- 
lirium ; head and limbs feel cold, numb, and heavy ; eyes 
fixed and hall closed ; pupils dilated and immovable ; face 
bloated and muscles relaxed ; opisthotonos, with constrictive 
feeling in the chest, and dyspnoea ; vomiting and colic ; abdo- 
men hard and swollen ; bowels loose or constipated ; convul- 



EPIDEMIC MENINGITIS. 213 

sions, with spasmodic jerkings of the limbs; painless paralysis ; 
anaesthesia ; hot or cold perspiration ; worse while sweating ; 
coma. 

Phosphorus. — Congestive headache, with burning and sting- 
ing pains in the occiput ; petechial and purpuric eruptions on 
the surface of the limbs or body; dulness of hearing; dysp- 
noea; frequent fainting; great prostration; tingling and tear- 
ing pains in the limbs ; laming pains in the spine. 

Plumbum. — Early paralytic symptoms ; heavy feeling in the 
back of the head ; retraction of the abdomen ; obstinate con- 
stipation ; somnolency; emaciation; contraction of the limbs; 
colic ; limbs feel too heavy to be moved. 

Rhus tox. — Vertigo, with heavy, bruised feeling in the brain, 
extending to the ears and back of the neck ; vesicular erup- 
tions on the face and upper part of the body ; great restless- 
ness, with aching pains in the limbs ; bruised feeling in the 
back and limbs ; somnolency ; bleeding at the nose ; dry 
cough, with perhaps bloody sputa. 

Veratrum alb. — Violent headache, with delirium ; vomiting, 
with convulsive shocks in the head as soon as the latter is 
raised ; stiffness of the neck, with bursting sensation in the 
head, and choking in the throat ; face pale, cold, and cadaver- 
ous looking; head thrown back, and rolling from side to side; 
convulsions, w T ith loss of sense and motion; coldness and 
numbness in the limbs; watery diarrhoea, attended with 
collapse. 

Veratrum vir. — Loss of consciousness, with coldness of the 
surface, slow, irregular and feeble pulse, and general prostra- 
tion of the vital power; vertigo, with dimness of vision, dilated 
pupils, and vomiting ; severe pain in the neck and shoulders ; 
sudden spasmodic action of the muscles of the face and limbs; 
convulsive twitchings, as from electric shocks; opisthotonos, 
with trismus ; trembling of the whole body ; pulse frequent 
and feeble. 

Zinc. — Retarded convalescence ; coldness of the body ; pros- 
tration of the vital power, with profuse and easy sweating ; 
trembling and twitching of the hands and feet ; priapism ; 
dysuria ; flatulent colic ; constipation ; weak, watery eyes ; 
flushes of heat in head and face ; weak memory. 



214 INTRACRANIAL DISEASES. 



CHAPTER VI. 

HEMORRHAGIC PACHYMENINGITIS. 

Syx. : Hematoma of the Dura Mater. 

This is a peculiar form of chronic inflammation of the in- 
ternal layer of the cerebral dura mater, resulting in the forma- 
tion of false membranes from which originate repeated attacks 
of haemorrhage, the latter constituting what is called hsematoma 
durse matris. 

Symptoms. — There are two stages in the history of this 
disease. The first is characterized by an intense headache, 
generally most severe at one particular point, which is fre- 
quently the vertex. Other less distinctive symptoms belong- 
ing to this stage are : more or less vertigo, mental confusion, 
uncertainty of movement, restlessness at night, contraction of 
the pupils, and occasionally, fever and convulsions, the latter 
especially in the case of children, in whom the disease gen- 
erally pursues a far less chronic course than it does in adults. 
The second stage, which includes the whole period from the 
first effusion of blood until the termination of the case, is char- 
acterized at first by a more or less rapid increase of mental 
hebetude, which gradually, but in an intermitting manner, 
passes from a state of somnolency to that of coma ; the rapidity 
depending, of course, on the rapidit} T of the effusion. The 
headache continues permanently fixed, the pupils contracted, 
and, whilst the patient is conscious, the vertigo and other 
brain symptoms more marked and troublesome. Thus we 
may have facial palsy, stammering, loss of voice, aphasia, un- 
steady gait, a voracious appetite, and constipation. When 
the hsematoma is unilateral we may have hemiplegia, more 
or less complete. At last, when the sac gives way, and the 



HEMORRHAGIC PACHYMENINGITIS. 215 

hemorrhage from the ruptured cyst spreads into the sur- 
rounding tissues, the symptoms of apoplexy, if not already 
fully developed by the previous pressure of the hematoma, 
now show themselves, producing complete loss of conscious- 
ness, hemiplegia or general paralysis, distortion of the face, 
difficulty of swallowing, great oppression of breathing, and 
finally death, which may or may not be preceded by delirium 
and convulsions. The duration of this stage, in the case of 
children, is usually only a few days ; whilst in adults it may 
continue for weeks and months. 

Morbid Anatomy and Pathology. — The first thing ob- 
served in these cases, according to Virchow, who made a 
special study of the disease, is hyperemia of the dura mater 
of the brain, especially of that portion of it which corresponds 
to the convexity. This leads to the formation of a false mem- 
brane on the internal surface of the dura, which at first is 
extremely thin, soft, and delicate, resembling somewhat the 
appearance of a spider's web. This membrane afterwards 
varies in consistence according to age, and is separable into 
two or more layers, sometimes even as many as twenty, each 
traversed by numerous fine blood-vessels. Owing to the great 
number and extreme delicacy of these newly-formed vessels, 
they are especially liable to become ruptured, and the effused 
blood, pressing upon the several layers of which the false 
membrane is composed, forms with it an organized sac, into 
which the subsequent effusions of blood are poured ; or the 
blood may be effused between the layers in one or more places, 
thus forming one or more simple or loculated cysts. The 
cysts adhere externally to the dura mater; internally they 
rest upon the arachnoid, covering the convolutions, which 
they compress and atrophy. They are generally situated 
near the middle line of the convexity, the general membrane 
of the hematoma often extending symmetrically on both sides. 
The contained blood is either in a liquid or a coagulated con- 
dition, and exhibits in different cases every stage of degenera- 
tion, according to the age of the hematoma. 

These views of Virchow, though generally received by 
pathologists, have been recently opposed by Huguenin and 



216 INTRACRANIAL DISEASES. 

others, who contend that the older doctrine, namely, that the 
hemorrhage precedes the formation of the* false membrane, 
is the correct one, and that the dura mater is not primarily 
inflamed, as Virchow asserts. At present, therefore, the pa- 
thology of the disease cannot be considered as definitely 
settled ; one party regarding the disease as a chronic pachy- 
meningitis, and the other as a truly hemorrhagic affection. 

Causes. — Hematoma generally occurs after fifty years of 
age, and is much more common in men than in women. It 
is, however, met with at all ages, especially in early child- 
hood, when it is almost as frequent as in advanced life: 

The disease is seldom, if ever, met with in healthy indi- 
viduals, but chiefly in those whose constitutions have become 
impaired by intemperance or old age, or weakened by such 
debilitating diseases as scurvy, delirium tremens, Bright's 
disease of the kidneys, anemia, haemophilia, diseases of the 
chest, etc. It also occurs in the subjects of insanity, and in 
persons who have suffered from a previous injury to the head. 

Diagnosis. — The diagnosis of hemorrhagic pachymenin- 
gitis, or hematoma of the dura mater, is a matter of great 
difficulty, and can seldom amount to more than a mere 
probability, as the symptoms are common to the various forms 
of cerebral and meningeal haemorrhage, as well as to other 
varieties of head trouble. Moreover, the disease is frequently 
associated with other cerebral disorders, the symptoms of 
which, occurring as they do simultaneously with those of the 
hematoma, often so modify or overshadow the latter as greatly 
to obscure the secondary affection. Those cases, however, 
where, after a period of headache, the symptoms of coma 
slowly supervene, and where at the same time there are no 
symptoms of any other form of localized injury to the brain 
or its membranes, we may reasonably refer to this category, 
especially if they occur in the aged, and are associated with 
a broken-down state of the system. Infantile hematoma is 
liable to be mistaken for tubercular meningitis, but the history 
of the case, and a careful comparison of all the symptoms of 
the two diseases, will generally lead to a correct diagnosis. 

Prognosis. — The prognosis, though extremely unfavorable, 



HEMORRHAGIC PACHYMENINGITIS. 217 

is not altogether hopeless, at least in the case of adults, as a 
number of cases are on record in which the symptoms of 
hematoma were present, and yet the patients recovered. 

Treatment. — Rest, cold to the head, and the homceopathi- 
cally indicated remedy, constitute the summum bonum in 
every case. AVe can therefore add nothing to the thera- 
peutic measures already given under the head of Cerebral 
Haemorrhage (q. v.). 



218 INTRACRANIAL DISEASES. 



CHAPTER VII 

CHRONIC HYDROCEPHALUS. 

Syn. : Dropsy of the Brain. 

This disease may be defined to be, a gradual effusion of serous 
fluid into the ventricles of the brain in such quantity as to 
distend them, and thereby enlarge the head. This definition 
purposely excludes those cases where the fluid has been found 
within the so-called cavity of the arachnoid, and which have 
probably resulted from an accidental rupture of the ventricular 
walls ; and also those cases where serum has accumulated be- 
neath the arachnoid as a sequence of cerebral atrophy or wast- 
ing — secondary affections which will be considered in the next 
chapter. 

Symptoms. — The disease is both congenital and acquired. 
Extra-uterine cases generally begin to manifest themselves 
during infancy, or soon after birth, before the cranial bones 
have become permanently united. In certain rare instances, 
however, the head commences to enlarge after the sutures have 
united ; up to, and even beyond, the period of middle life. 

The earlier symptoms may precede the beginning of the en- 
largement, and vice versa. In the former case, symptoms more 
or less resembling those of acute hydrocephalus set in, and are 
soon followed by a perceptible enlargement of the head ; or, 
the irritative symptoms abate and become more or less chronic 
before the head commences to enlarge, so that for a time the 
practitioner may be in doubt as to the real nature of the dis- 
ease. Sooner or later, however, the enlargement begins to 
manifest itself; and as this continues gradually to increase — 
even though, as sometimes occurs, no other 'symptom may 
show itself for a considerable period — there can no longer be 



CHRONIC HYDROCEPHALUS. 219 

any room for doubt. The disease is now not only quite mani- 
fest to the eye, but the patient has a somewhat uncertain and 
tottering gait, which is often characteristic of the affection, 
especially in the case of children. As the disease advances, 
the child becomes dull and peevish ; tremors of the limbs set 
in, so that he can no longer walk ; the senses gradually fail ; 
there is more or less insensibility of the skin ; taste becomes 
perverted and weak; the sense of smell is diminished; dim- 
ness of vision follows; and finally hearing itself fails. The 
digestive functions generally remain longer unimpaired, but 
they, too, at last become involved ; vomiting occurs, and ema- 
ciation, notwithstanding an increase in the amount of food, is 
likewise produced. Costiveness and scanty urine are also 
attendant symptoms. At last, symptoms of paralysis set in, 
the eyes are turned to one side, the pupils are dilated, and 
vision is either greatly impaired or becomes extinct. The rec- 
tum and bladder become implicated, so as to lose all control 
over their contents. Finally, after successive attacks of spasms 
and convulsions, the paralysis becomes complete; suffocative 
fits occur, during which the breathing becomes labored and 
stertorous ; insensibility follows ; the pulse becomes small, 
feeble, and intermitting; and death finally closes the scene. 

Such is the general history of most cases; but sometimes, 
owing to a fall or blow upon the head, or some other cause, 
convulsions occur at a much earlier period ; or it may be that 
apoplectic symptoms, such as coma and paralysis, take prece- 
dence of all other phenomena. This is especially apt to be the 
case in adults, owing to the unyielding condition of the cra- 
nium. Moreover, complications are liable to occur, resulting 
perhaps from the presence of a cerebral tumor, or some other 
primary intracranial affection, and then the symptoms will be 
correspondingly modified. Thus, if under these circumstances 
we make an ophthalmoscopic examination of the fundus of 
the eye, we may find, even at a comparatively early period of 
the disease, a well-developed optic neuritis ; a condition which 
in these cases will sooner or later terminate in amaurosis or 
true blindness. 

Morbid Anatomy and Pathology. — The bones of the era- 



220 INTRACRANIAL DISEASES. 

nium are found in one of two conditions, either with the fon- 
tanelles open and the sutures widely separated, or else with 
the sutures, and perhaps the fontanelles also, completely closed. 
The latter may represent cases which have become stationary, 
or more than usually chronic ; but of this we have no certain 
evidence. The bones of the cranial vault are generally more 
or less thinned or atrophied from pressure, but this is not 
always the case ; on the contrary, they are sometimes thick- 
ened, and that, too, even in children. As the bones of the 
face usually remain firmly united, whilst those of the vault are 
w T idely separated from each other, the head generally presents 
a peculiar wedge-shaped appearance, especially when the en- 
largement is extreme. In these cases the forehead is so prom- 
inent as to overhang the face, whilst the eyeballs are deeply 
sunk in their sockets ; and as the face is either unchanged or 
more or less emaciated, the disproportion between them is so 
remarkable as to make the expression highly characteristic of 
the disease (fades hydrocephalica). 

The amount of fluid contained within the cranium is some- 
times enormous, amounting in one case, it is said, to twenty- 
seven pounds. In this case, although the child was only six- 
teen months old, the head measured fifty -two inches in circum- 
ference. Where the head is so large as to be greatly dispro- 
portioned to the size or age of the child, of course it cannot be 
maintained in an upright position without the aid of the 
hands or of some artificial support. Generally, this is not at- 
tempted, but the child is kept in a horizontal or recumbent 
position. 

As the ventricles become more and more distended by the 
gradually accumulating fluid, the hemispheres slowly expand, 
the convolutions unfold, and the whole cerebral mass becomes 
thinned and distended, until at last it resembles a mere bag 
of brain-matter filled by the expanded ventricular membranes 
and their fluid contents. At the same time, both the mem- 
branes and the brain substance, instead of becoming softer and 
less compact, are rendered tougher and more dense, the lining 
membrane of the ventricles thicker and more resisting, the 
brain-matter tougher than natural. Possibly this may be 



CHRONIC HYDROCEPHALUS. 221 

due in some cases, in part at least, to previous inflammatory 
action, but numerous post-mortem examinations prove con- 
clusively that this cannot always, nor even generally, be the 
case ; for whilst the brain substance rarely shows signs of 
atrophy, there is apparently an overgrowth of the neuroglia — 
the result probably of the long-continued mechanical conges- 
tion of the tissues. That this explanation is the true one, ap- 
pears evident also from the fact that no other signs of inflam- 
mation are to be found in these cases, except in a few rare 
instances, where the presence of a tumor or some other intra- 
cranial affection affords a sufficient explanation of its existence. 

Causes. — We have just referred to one of the supposed 
causes of chronic hydrocephalus, namely, inflammation of 
the lining membrane of the ventricles. The disease may also 
be an occasional sequela of acute hydrocephalus {tubercular men- 
ingitis), but as there is no absolute proof of this, we can only 
regard it as a probable supposition. A third and doubtless 
much more frequent cause of the dropsy, is to be found in the 
mechanical congestion of the great veins of Galen by the press- 
ure of tumors and other morbid growths upon the straight 
sinus, as this would have a direct tendency to produce the con- 
gestion in question. The disease, though generally confined 
to children, is occasionally met with in adult, middle, and 
more advanced life. Congenital cases are comparatively rare ; 
and owing partly to mechanical violence, and, in some cases, 
to defective development of the cerebral mass, generally prove 
fatal at the time of birth. 

Diagnosis. — After the head begins to enlarge there can 
generally be no difficulty in recognizing the disease at once, 
but previous to this period it can only be a matter of conject- 
ure. When the enlargement is inconsiderable the practi- 
tioner, in forming a diagnosis, should take into consideration 
the shape of the head, as well as the general character of the 
symptoms, since the heads of healthy children often vary con- 
siderably in point of size, and what might justly be regarded 
as a large head in the offspring of some parents, would only 
be of natural, or even small dimensions in that of others. 

Prognosis. — Although chronic hydrocephalus is generally 



222 INTRACRANIAL DISEASES. 

fatal, sooner or later, it is not always so. A considerable 
number of cases live a good many years after the setting in of 
the disease ; whilst a few even appear to have recovered. As 
a general rule, however, death takes place within one or two 
years. Sometimes the disease is stationary for a considerable 
period, and then perhaps it will make rapid progress again, 
so that it is difficult to say, in any instance, whether medicine 
has had any curative influence over it or not. Death com- 
monly occurs from exhaustion ; but sometimes the patient is 
carried off by convulsions, or by some intercurrent disease, as 
pneumonia or pleurisy. 

Treatment. — This may be either general or local. Local 
treatment has in the great majority of instances been produc- 
tive of more harm than good. Tapping is claimed to have 
permanently relieved a few cases, but the ordinary result of 
the measure, as might have heen anticipated, has been to 
hasten, and sometimes to cause a fatal termination, by excit- 
ing inflammation of the brain and its membranes. Compres- 
sion has also for the most part either proved entirely nugatory, 
or else has been attended with dangerous consequences from 
compression from both the brain and the pericranial vessels. 

Special Indications. — Arsenicum. — Swelling, particularly of the 
head and face ; vomiting on being raised up in bed ; impair- 
ment of the special senses; emaciation and muscular weak- 
ness ; constipation ; retention, or involuntary discharge of 
urine ; anxious and oppressed breathing at night, or when in 
bed ; thirst ; the child strikes its head, as though for tem- 
porary relief. 

Calcarea carb. — Scrofulous swellings ; old, pale, and haggard 
expression of countenance; face swollen or puffed; great 
weakness of the limbs ; spasms and convulsions ; small, feeble 
pulse ; suppression of urine ; paralysis ; anterior fontanelle 
wide open ; head very large ; copious perspiration on the 
head and shoulders, especially when sleeping. 

Calcarea phos. — Head greatly enlarged ; face pale, sallow, or 
yellowish ; look stupid ; eyes turned to one side ; ears and 
nose cold ; posterior fontanelle fails to close ; child unable to 



CHRONIC HYDROCEPHALUS. 223 

hold up its head ; takes no interest in anything ; always worse 
about sundown. 

Helleborus. — Dulness of the senses; somnolency; face pale 
and sallow ; limbs tremble from weakness ; tottering gait ; 
spasms and convulsions; suppression of the urine; paralysis; 
strabismus ; forehead covered with a cold sweat ; dilated pu- 
pils ; passive congestion of the brain and its membranes, with 
serous effusion. 

Kali iod. — Scrofulous constitutions; dilated pupils; blind- 
ness ; pains in the head, especially in the occiput; stupor, with 
labored and irregular respiration ; emaciation and prostration ; 
urine suppressed; paralysis; intercurrent pneumonia ; cerebral 
congestion, with serous effusion; symptoms aggravated at 
night. 

Lachesis. — Symptoms of apoplexy, attended with paralysis ; 
head enlarged, heavy, and painful; pain worse about the 
occiput; vertigo; dulness of sight; mental hebetude; ten- 
dency to fainting; convulsions, with coldness of the feet; face 
sunken ; moaning during coma ; difficult deglutition. 

Mercurius. — Great restlessness ; enlargement of the head ; 
impairment of the special senses ; spasms and convulsions ; 
paralysis ; dilated pupils ; collapse of the system. 

Plumbum. — Heaviness of the head from dropsy of the brain, 
with pressure as though the skull was too full; emaciation, 
with trembling of the limbs ; restlessness and sleeplessness, or 
somnolence with dulness of the senses ; weariness and increas- 
ing debility ; nausea and vomiting ; obstinate constipation ; 
retention, or involuntary emission of urine ; spasms, convul- 
sions, and paralysis ; pulse small and frequent, or slow and 
feeble. 

Phosphorus. — Dull and inclined to somnolency ; coldness of 
the extremities ; child vomits as soon as the drink becomes 
warm in the stomach ; stool voided with difficulty ; convul- 
sions, followed by collapse ; pneumonic symptoms ; very rest- 
less, and always worse after sleep ; great weakness, so that he 
has to lie down ; emaciation ; paralysis, with difficult respira- 
tion and fear of suffocation. 

Psorinum. — Stuporfaction and mental dulness from cerebral 



224 INTRACRANIAL DISEASES. 

congestion; aversion to having the head uncovered; anxious 
dyspnoea, worse when sitting up ; painful pressure in the 
occiput; profuse sweating when asleep or on making the least 
exertion; vertigo with headache; ulcers on the legs ; extreme 
prostration ; trembling of the limbs from weakness ; scrofu- 
lous subjects. 

Silicea. — Head enlarged, and feeling as if it was filled with 
living things ; dulness of the senses ; face pale ; stool and 
urine suppressed ; suffocative breathing ; great prostration 
and muscular weakness ; convulsions ; numbness, with para- 
lytic weakness of the limbs ; scrofulous constitution. 

Sulphur. — Especially valuable as an intercurrent remedy, 
especially in scrofulous subjects; head enlarged; gait totter- 
ing ; dulness of the senses ; face pale and emaciated ; consti- 
pation ; retention of urine ; paralysis. 

Zincum met. — Head enlarged, with great outward pressure; 
stupefying headache, with dulness of the senses ; restlessness, 
especially at night, with frightful dreams ; vertigo, with sud- 
den obscuration of sight ; sudden loss of consciousness, with 
coldness of the body, small, weak pulse, oppression of breath- 
ing, and great prostration ; tremor of the limbs, with sense of 
heaviness in them; constipation; nausea with trembling; 
cerebral paralysis; symptoms worse in the afternoon and 
evening. 



FOREIGN PRODUCTS. 225 



CHAPTER VIII. 

FOKEIGN PEODUCTS. 

Having in the respective chapters on cerebral tumors and 
syphilis (q. v.) treated in detail of the various new growths, not 
only of the cerebrum itself, but also of its membranes — includ- 
ing the important subjects of cancer, tubercle, and syphilis — it 
only remains for us here to discuss certain adventitious pro- 
ducts belonging more especially to the cerebral membranes. 

1. Serum. — This fluid, as we have just seen, is present in the 
greatest quantity in chronic hydrocephalus. We also meet 
with it in excess in two other conditions. First, within the so- 
called cavity of the arachnoid (external hydrocephalus), or, what 
is the same thing, between that membrane and the epithelial 
lining of the dura mater. It is difficult to account for its pres- 
ence in this situation, unless we regard it either as the result 
of a previous chronic inflammation of the inclosing mem- 
branes, or else as having escaped in some manner from the 
ventricles during an attack of internal hydrocephalus. The 
latter supposition is the more probable, at least in the majority 
of instances. (See Chronic Hydrocephalus) 

Secondly, the fluid is met with beneath the arachnoid, or 
between that membrane and the pia mater, in cases where the 
cerebral convolutions have become atrophied from pressure or 
senile degeneration. To this class, also, belong those cases 
sometimes met with in old people who have died suddenly 
from what is called "serous apoplexy" — a misnomer arising 
from mistaking the effect for the cause. For the excess of 
serum beneath the arachnoid in these cases doubtless results, 
not from vascular congestion, but from an exosmosis caused 
by the shrinkage of the cerebral convolutions in senile atrophy. 

15 



22G INTRACRANIAL DISEASES. 

2. Thrombi. — Thrombosis of the cerebral sinuses occurs for 
the most part in two situations, namely, in the longitudinal 
sinus, and in the lateral sinuses. 

a. The symptoms of thrombosis of the longitudinal sinus are ex- 
tremely variable and uncertain ; for whilst oedema of the fron- 
tal veins, exophthalmus, epistaxis, and even insanity, have been 
attributed to this cause, instances are on record where the lon- 
gitudinal sinus has been found entirely blocked by a throm- 
bus, without having given rise to any recognizable symptoms 
during life. In other cases, on the other hand, in addition to the 
symptoms already mentioned, abscesses have been formed in 
different parts of the body. This is explained by the fact that 
the thrombus sometimes sets up an inflammatory action in the 
sinus, in consequence of which pus gains access to the general 
circulation, and thereby leads to the formation of abscesses in 
remote parts. 

b. The symptoms attending the formation of a thrombus in 
one of the lateral sinuses, are just as indefinite and unreliable 
as in the case of the longitudinal sinus. Thus, Gerhardt* 
attributes to this cause a difference in the size of the external 
jugular veins, that of the affected size being smaller than the 
other ; whilst Prichardf and others have reported cases of the 
kind attended by delirium, convulsions, coma and paralysis. 
It appears, therefore, that thrombus of the cerebral sinuses is 
not accompanied by any such characteristic symptoms as will 
identify the disease, or lead to anything more than a mere sus- 
picion of its existence. 

It sometimes happens that a thrombus of the longitudinal 
sinus becomes prolonged through the straight sinus to the tor- 
cular Herophili, and thence into one or both of the lateral 
sinuses. In these cases more or less extensive softenings of the 
brain are apt to be produced. These sometimes consist of 
small superficial patches, of a reddish color, in the cerebral 
cortex; but occasionally they embrace considerable portions 
of the brain substance. Ventricular and subarachnoidean 



* Deutsche Klinik, 1857, JS T o. 45. 

f Treat, on Bis. of Nerv. Sys., London, p. 176. 



FOREIGN PRODUCTS. 227 

effusions of serum also occur, as well as capillary haemorrhages ; 
the latter are likewise occasionally found in the grey matter of 
the hemispheres. 

Thrombosis of the lateral sinuses is generally secondary to 
caries of the cranial bones, or to the extension of inflamma- 
tion from the cerebral tissues to the sinuses. Suppurative 
otitis is a prolific cause of the affection, no less than three- 
fourths of the recorded cases being referred to this origin. 
Thrombosis of the longitudinal sinus, however, may result 
from any cause capable of retarding the general circulation, or 
of rendering it slow, feeble, and irregular, as this favors the 
coagulation of the blood in the veins and sinuses. This is 
especially true of those diseases which obstruct the flow of 
blood from the head, such as tumors of the neck, or exces- 
sively developed Pacchionian bodies, wdrich have been known 
to project into the sinus. Old age appears to favor the pro- 
duction of meningeal thrombi, especially the primar} 7 form ; 
they are not, however, by any means confined to the aged, but 
are also met with in the early as w 7 ell as in the middle periods 
of life. 

3. Parasites. — These are known as cysticerci and hydatids. 
They are both larval forms of different species of tape-worm. 

(«) Cysticercus is the larval state of Tenia solium. It has the 
appearance of a small bladder, and is about the size of a pea 
or bean. It is situated for the most part in the grey or cortical 
substance of the brain, but is sometimes found in the men- 
inges. Griesinger, who examined upwards of fifty cases, 
found the symptoms exceedingly variable, and occasionally 
entirely wanting. In the former class, the leading symptom 
is epilepsy, either with or without mental disturbance ; but 
sometimes the mental disorder may exist without giving rise 
to epilepsy. But since there is nothing peculiar about either 
the epilepsy or the psychical phenomena in these cases, it is 
scarcely possible to found a diagnosis upon them. This is of 
less importance, however, since they are comparatively short- 
lived, calcareous degeneration setting in within eight months 
or less from the time of their first appearance. Infection is 
probably due to the eating of " measly " pork in a raw or in- 



228 INTRACRANIAL DISEASES. 

sufficiently cooked condition — the so-called pork-measle being 
specifically identical, according to most authorities, with the 
form usually found in man. Dr. Giacomini, however, says 
that the human measle commonly carries thirty-two cephalic 
hooks, whilst the pork-measle displays only twenty-four. 

(0) Hydatids are larval states of Tenia echinococus, a minute 
tape-worm infesting the alimentary canal of the dog and wolf. 
As met with in the brain, they are always in the aborted or 
sexually immature condition (acephalocysts). They vary in 
size from that of a small grape up to a large apple or orange. 
Usually they are solitary ; but sometimes several exist in the 
same brain. Out of seven hundred cases in the human sub- 
ject collected by Devaine and Cobbold, six per cent, were intra- 
cranial. Out of twenty-four recorded cases in which the age 
was stated, Bastian found that no less than eighteen of them 
were persons between the ages of ten and thirty years ; of the 
remainder, three were above and three below these extremes.* 
The fondling of dogs is doubtless a fruitful means of infection ; 
and so, also, is the drinking of water or the eating of salad 
contaminated by the ova voided by these animals. When we 
remember that nearly one- sixth of all the inhabitants dying 
in Iceland fall victims to hydatids, and that the disease is 
rapidly on the increase in our own and other countries, it be- 
comes a serious question whether any one is justified in mak- 
ing a household pet even of so noble an animal as the dog. 

Prognosis. — The peculiar circumstances attending each 
case must be considered in forming a prognosis; for, as we 
have seen, some of these adventitious products are not always 
accompanied by grave symptoms, whilst others sometimes 
exist without giving rise to any serious or even recognizable 
disturbances. Moreover, in the case of hydatids, it is not im- 
possible for a spontaneous cure to take place. Nevertheless, 
as a general rule, foreign products within the cerebral mem- 
branes are attended with the most serious consequences to the 
health, and eventually, also, to the life, of the patient. 

Treatment. — Medical treatment, in these cases, generally 

* Quain's Die. of Med., p. 755. 



FOREIGN PRODUCTS. 229 

resolves itself into the relief of individual symptoms, that is to 
say, it is merely palliative. There can be no specific curative 
treatment, homoeopathic or otherwise, for those suffering from 
the existence of intracranial parasites, or from the occurrence 
of thrombi in the longitudinal or lateral sinuses. We may be 
able to mitigate to some extent the severity of convulsions, 
relieve headache, and promote sleep in such cases, but more 
than this we are not likely to accomplish. The proper reme- 
dies to meet these several indications, will readily suggest 
themselves to every practitioner. 



230 INTRACRANIAL DISEASES. 



SECTION III. 

SYMPTOMATIC AFFECTIONS. 

CHAPTER I. 

CEPHALALGIA, OK HEADACHE. 

Headache is a symptomatic affection in every sense of the 
word. It may or it may not be associated with structural 
changes in the head or elsewhere, but it is nevertheless a func- 
tional disturbance, dependent upon some physical or mental 
condition of which it is a symptom, and not the disease itself. 
Such, however, is its prominence in many cases, coupled with 
the fact that it oftentimes constitutes the only symptom of 
which the patient complains, that it even takes high rank as 
a distinct affection, and is justly entitled to receive special con- 
sideration at our hands. 

Varieties. — Headache presents numerous varieties, which 
may be classified as follows : 

1. Accession. — Sudden, gradual, etc. 

2. Intensity. — Slight, moderate, severe, etc. 

3. Character. — Dull, sharp, stinging, shooting, cutting, stu- 
pefying, etc. The headache may be simple, or associated with 
other symptoms, such as vertigo, disorders of vision, derange- 
ment of the stomach, etc. 

4. Duration. — Continual or periodic ; intermitting, remitting, 
weekly, monthly, etc. It may be momentary, or it may last 
many hours, days, or months. 

5. Location. — Superficial or deep-seated ; general, more or less 



CONGESTIVE HEADACHE. 231 

diffused, or confined to particular parts of the head, as the 
forehead, temples, vertex, occiput, etc, 

6. Nature. — Congestive, anaemic, nervous, toxaemic, etc. 

(a) Species. — Eheumatic, syphilitic, menstrual, hysterical, 
neuralgic, etc. 

(,?) Claims. — Limited to a particular spot, with the sensation 
as of a nail being driven into the head at that point. 

(y) Hemicrania. — Limited chiefly to one side of the head, 
and of a nervous character. 

For convenience of reference, we shall treat of the several 
kinds of headache under their respective names. 

1. Congestive Headache. 

Many forms of headache are attended with a greater or less 
degree of cerebral hyperseinia, but only those are entitled to 
be regarded as congestive, that depend upon an increased 
fulness of the vessels of the brain. They are of two kinds. 
In one the congestion is active ; in the other, passive. 

In the active form, the pain is of a throbbing, pulsative 
character, and may be either sharp or obtuse. It may be 
general, involving the whole brain, or it may affect only a 
part of the head, as the forehead, vertex, occiput, etc. There 
is in these cases usually more or less flushing of the face, ring- 
ing and throbbing in the ears, glistening of the eyes, sensitive- 
ness to noise and light, and vertigo or giddiness, especially 
on stooping. The condition may be caused by a plethoric 
state of the system, menstrual irregularities, emotional excite- 
ment, excessive mental exertion, hypertrophy of the left ven- 
tricle, and many other influences. 

In the passive form of congestive headache, the pain is 
usually of a dull, oppressive character, and is attended by a 
sense of fulness or distention, and by a tendency to stupor. 
Vertigo is generally present, and not unfrequently there are 
slight mental irregularities, such as illusions, delusions, and 
hallucinations. But the tendency to somnolency is the most 
marked and characteristic symptom. Sleep, even when most 
natural, is apt to be accompanied by frightful dreams. When 



232 INTRACRANIAL DISEASES. 

caused, as it frequently is, by debility or exhaustion, the pain 
is usually in the top of the head, or across the forehead. 
When produced by leucorrhoea, diseases of the uterus, etc., 
the pain is generally in the vertex or occiput. Congestive 
headaches of a passive character may also be caused by any 
condition or affection which impedes the return of blood from 
the head, such as tight collars, tumors in the neck, valvular 
defects of the heart, dilatation of the right ventricle, dyspnoea, 
deficient action of the liver, constipation, drunkenness, a de- 
pendent position of the head, etc. 

Special Indications. — Aconite. — Cerebral congestion in san- 
guine or plethoric persons, especially when characterized by 
violent, unbearable, or stupefying pains, chiefly in the temples 
and forehead ; also when there is fever, with nausea and vom- 
iting; excessive sensibility and fearfulness; intolerance of 
light, noise, or touch ; burning headache, as if the brain were 
too hot; throbbing and piercing pains in the forehead, temples, 
and top of the head. 

Agaricus. — Headache with fever and delirium : dull oppres- 
sive pains, chiefly in the forehead, causing the patient to close 
his eyes ; disposition to constantly move the head to and fro ; 
vertigo, especially when brought on by excessive mental exer- 
tion ; nervous twitchings about the face and head. 

Ailanthus. — Headaches characterized by fulness of the head, 
with burning pains, heat, darting in the temples and occiput, 
vertigo, and nausea ; severe headache, with dizziness, and hot, 
red face ; darting pains through the temples and occiput, with 
mental confusion ; vertigo when stooping. 

Aluminum. — Headache attended by congestion of blood to 
the head and face, heavy, oppressive feeling in the forehead, 
rush of blood to the eyes and nose, or with nausea and epis- 
taxis ; throbbing frontal pains, worse on movement, especially 
on going up stairs ; amelioration from pressure. 

Ammonium carb. — Congestive headache characterized by 
beating, pulsating, and pressing pains in the forehead and top 
of the head, feeling as though it would burst; nausea, especially 
in the morning before rising; rush of blood to the head; aggra- 



CONGESTIVE HEADACHE. 233 

vated by eating, or by walking in the open air ; ameliorated 
by pressure ; fat persons who lead sedentary lives. 

Amyl nitrite. — Congestive headache attended with heat and 
violent throbbing in the head, and accompanied with a feeling 
of intense fulness, as though it must burst; flushing of the 
face, with visible pulsation in the carotids, which extends to 
the head and temples ; aggravated by motion, and by being in 
a warm room. 

Apis mel. — Headache attended by congestion to the head 
and face ; sense of fulness in the head, accompanied by ver- 
tigo and heaviness ; burning, throbbing headache, aggravated 
by motion, and ameliorated by temporarily pressing the head 
with the hands, or with a tight bandage. 

Arnica. — Congestive headache in sanguine plethoric sub- 
jects ; aching, darting, and pressive pains, mostly in the fore- 
head ; pressive headache, feeling as though the head were 
being distended; burning on top of the head and in the brain; 
vertigo, especially when walking; headache aggravated by 
motion and by mental exertion. 

Asclepias syrica. — Congestive headache, with vertigo, dul- 
ness, and somnolency ; violent headache accompanied by ex- 
treme nausea; urine scanty. Adapted to cases of passive 
congestion, especially where the headache has been caused by 
suppressed perspiration. 

Atropine. — Headache attended by flushing of the face, rush 
of blood to the head, and tendency to bleeding at the nose ; 
aggravated by motion, especially walking or stepping. This 
remedy is especially valuable in cases where Belladonna has 
been tried and failed, or only afforded temporary benefit, 
though apparently indicated by the symptoms. 

Belladonna. — Congestive headache accompanied by red, 
bloated face, injected eyes, vertigo, sensitiveness to light, noise, 
or contact, and with tendency to stupor; pressive frontal 
headache almost closing the eyes, and feeling as if the brain 
would be pressed out; violent throbbing in the head, with 
pains extending in every direction ; great fulness, and violent 
expansive pains, feeling as though the head would split open, 
or as if the contents would be forced through the head, espe- 



234 INTRACRANIAL DISEASES. 

cially the forehead; carotids throb violently and the jugular 
veins are swollen ; loss of consciousness ; pain aggravated by 
stooping, or rising from a stooping position. 

Bryonia. — Headache attended by rush of blood to the head, 
vertigo, pressure and great heaviness in the head, especially 
when caused by derangement of the stomach ; heat in the 
head, with burning pains in the forehead ; vertigo and mental 
confusion on the least motion ; nausea and vomiting ; worse 
after eating, in the evening, and on stooping. 

Cactus grand. — Headache from congestion to the brain, espe- 
cially when accompanied by, or dependent on, cardiac disturb- 
ances; eyes red and injected, face flushed, and sensitive to 
light and noise; sense of constriction about the heart, as if 
held by an iron hand ; palpitations of the heart, attended by 
headache, and aggravated by mental emotion ; pulsations in 
the head, especially in the temples, and accompanied by a 
bursting feeling, as though the skull would give way. 

Caladium. — Headache, with heat in the head, which ascends 
from below and becomes an internal, burning heat ; pressive 
headache after dinner ; bursting headache, especially in the 
forehead ; stupefying pressure in the right temple on waking; 
vertigo, with confusion and whirling sensation in the head. 

Calcarea carb. — Congestive headache, associated with an im- 
poverished condition of the blood ; the pains are chiefly felt in 
the forehead, vertex, and sides of the head ; throbbing pains 
in the middle of the brain, lasting all day ; stupefying, oppres- 
sive headache in the forehead ; pains, accompanied by nausea, 
vomiting, anxiety,' difficulty in thinking, and dimness of 
vision; worse from mental exertion, talking, walking, or going 
up stairs ; ameliorated by tight bandaging, vomiting, lying 
down, and from cold applications to the head. 

Camphor. — Congestive headache, characterized by throbbing, 
which beats like a hammer in the occiput ; head hot, face red, 
but limbs cool ; anxiety, with great restlessness ; frontal head- 
ache, pressing outward ; vertigo, with heaviness in the head ; 
pains excited and aggravated by motion. 

Capsicum. — Headache, accompanied by a sensation of ful- 
ness in the head ; throbbing, pressing, and tearing pains ; 



CONGESTIVE HEADACHE. 235 

pains chiefly in the forehead and temples ; sensation as if the 
head would burst ; vertigo, with nausea and vomiting ; con- 
fusion of the head, and mental dulness ; burning in the eyes, 
with redness and lachrymation ; amelioration from warmth, 
and from lying with the head elevated. 

Carbo an. — Headache of a congestive character, attended by 
heat in the head, vertigo, confusion of thought, and throbbing, 
bursting, or pressing pains, chiefly in the forehead and top of 
the head ; vertigo, with nausea, dimness of vision, and pros- 
tration ; ameliorated by pressing the hands upon the vertex, 
or going into the open air. 

Carbo veg. — Pressing, throbbing pains in the head, especially 
over the eyes; beating headache in the afternoon; heat and 
pain in the forehead, with confused feeling in the head, re- 
lieved by epistaxis ; vertigo, especially on stooping. Suitable 
to weak, cachetic, and aged people, and also children, especially 
after exhausting diseases. 

Causticum. — Headache, with sensation of heat and fulness in 
the head ; throbbing, tearing pains, chiefly in the vertex, 
spreading to the forehead and sides ; pain occurs in paroxysms, 
moving forward ; accompanied with nausea, palpitation of the 
heart, and hurried respiration ; rush of blood to the head, 
with vertigo and anxiety ; aggravated by stooping, reading, 
shaking the head, and in the evening ; ameliorated in the open 
air, and by applying cold water to the head. 

Chamomilla, — Headache of a pressive character, the press- 
ure extending from the top of the head to the forehead and 
temples ; pressure increasing and decreasing, especially in the 
right half of the brain ; pressing headache as from a stone in 
the head, worse in the evening ; vertigo, with a tendency to 
faintness ; pains aggravated by mental exertion and by sudden 
stooping. 

China — Congestive headache in anaemic individuals, or 
from loss of animal fluids ; violent pressive headache deep in 
the brain ; pressure from within outward, especially over the 
eyes ; intense throbbing headache coming on after the loss of 
blood ; headache following sexual excesses or onanism ; ameli- 
orated by hard pressure and by lying down. 



236 INTRACRANIAL DISEASES. 

Cimicifuga. — Congestive headache, especially of a passive 
character ; constant dull pain in the head, beginning in the 
occiput and extending to the vertex ; dull frontal headache, 
relieved by pressure; severe pain in the eyeballs, extending 
into the forehead, and increased by any movement of the 
head or eyes ; intense throbbing pain, as if a ball were driven 
from the neck to the vertex with every throb of the heart ; 
rush of blood to the head, with vertigo, impaired vision, dul- 
ness, and aching fulness in the vertex ; aggravated by move- 
ment ; ameliorated in the open air and by pressure. 

Cocculus. — Tearing, throbbing headache, especially in the 
evening ; a violent headache which compels the patient to sit 
up, aggravated by talking, laughing, noise, or a bright light ; 
noise excites vomiting ; ameliorated b} r quiet and warmth. 

Cuprum. — Headache with fulness, heaviness, and dulness ; 
congestion to the head, with convulsions ; face purplish-red ; 
vertigo when looking upward, with vanishing of sight, as 
though a mist was before the eyes ; delirium, fearfulness, cold- 
ness of the limbs ; aggravated by motion, pressure, and even 
contact. 

Digitalis. — Throbbing headache in the forehead ; pressure 
in the forehead and temples, or in the whole head, disappear- 
ing and reappearing periodically in different parts ; headache, 
pressure and weight, as if caused by congestion of blood to 
the head ; fainting fits with inclination to vomit ; vertigo, 
with anxious sensation, as if fainting would occur ; pulse ir- 
regular or intermitting, and excited by the least movement 
or emotion ; worse also when exerting the mind, or when in a 
w T arm room. Especially suited to cardiac complications. 

Dulcamara. — Dull, heavy, stupefying headache, aggravated 
by the least movement, or by speaking; congestion to the 
head, with buzzing in the ears, and dulness of hearing ; con- 
dition aggravated by cold and damp weather, and especially 
by getting the feet wet ; ameliorated by lying down. 

Ferrum acet. — Congestive headache in anaemic persons, or 
those who have lost much blood, or other animal fluids; 
hammering and throbbing headache, especially in the frontal 
region; feeling as if the head would burst; rush of blood to 



CONGESTIVE HEADACHE. 237 

the head, with swelling of the veins of the head, and slight 
flushes of heat; severe frontal headache, with cold feet. 

Fluoric acid. — Congestion of blood to the head, especially 
the forehead ; severe pressing pain in both temples from 
within outward ; vertigo with nausea, heat and pain in the 
head ; sensation of numbness in the head, with heaviness and 
compressive pains; heaviness above the eyes, with nausea, 
aggravated by motion. 

Gelsemium. — Headache associated with stupor and heavi- 
ness; sense of weight and pressure in the head; excruciating 
headache, accompanied by slight nausea; pain most fre- 
quently in the occiput, or else in the forehead and temples ; 
heaviness of the head, alleviated on profuse emission of urine; 
intense congestion of the brain in children during denti- 
tion ; great heaviness of the eyelids ; disposition to sleep, with 
great prostration of the whole muscular system ; aggravated 
by lying down, or by bandaging ; ameliorated by bending the 
head forward or backward, or by shaking it. 

Glonoin. — Great heat and throbbing in the whole head, es- 
pecially in the temples and over the eyes ; pressive pain from 
within outward in both temples ; extreme congestion in the 
head, with red face, and violent beating in the temporal 
arteries ; brain feels as if moving in waves and expanding 
itself; vertigo during and after stooping, lasting several min- 
utes, with nausea ; congestion to the head and face, with red- 
ness of the e} T es, and roaring in the ears; aggravated by 
shaking or jarring the head, stooping, mental exertion, or 
wine ; ameliorated in the open air and by pressure. 

Gratiola. — Congestive headache, with fulness and heavi- 
ness in the forehead, throbbing in the temples, burning in the 
face, and vertigo with nausea ; rush of blood to the head, with 
throbbing in the forehead ; vertigo, with black before the eyes, 
aggravated by motion ; heat in the head after rising from a 
stooping posture. 

Gymnocladus. — Feeling of fulness in the head, with throb- 
bing in the forehead and temples, and accompanied with heat 
in the face, pain in the eyes, and vertigo ; face swollen and 
hot, with burning sensation, as in erysipelas; fulness and 



238 INTRACRANIAL DISEASES. 

pressure in and over the eyes, extending to the vertex ; gen- 
eral tired feeling, with numbness of the body ; worse in the 
evening. 

Hamamelis. — Headaches resulting from passive congestion 
of the venous system generally, especially in the lungs and 
portal system ; flushing of the face, with throbbing, aching, 
and sense of fulness in the head, which feels as though it 
would burst; bursting headache, aggravated by bending for- 
ward ; passive congestion of brain, accompanied by vertigo, 
nausea, and tendency to epistaxis ; bleeding haemorrhoids. 

Iodine. — Violent, almost unbearable headache, with confu- 
sion of mind ; throbbing pains in the head at every motion ; 
violent aching in the occiput ; rush of blood to the head, with 
vertigo ; palpitation of the heart ; bluish lips, with swelling of 
the superficial veins; glandular swellings. Adapted to cases 
of passive congestive headaches ; also to chronic cases, espe- 
cially in old people. 

Kali carb. — Congestive headache, with violent throbbing 
and hammering; aching, pressing pain in the back of the 
head ; determination of blood to the head, producing a sense 
of intoxication ; sensitive to noise, irritable, and peevish ; gid- 
diness with nausea ; constipation ; aggravated by stooping, 
moving the head, eyes, or jaw. Especially suited to aged 
people; particularly if inclined to obesity. 

Kali iod. — Violent beating, hammering pains in the fore- 
head, with a sensation as though the head were greatly en- 
larged ; pain in the vertex as though it would burst ; vertigo 
after meals ; flushes of heat, with dulness of the mind ; throb- 
bing and burning pains in the nasal and frontal bones ; swell- 
ing of the cervical glands ; pains worse in the afternoon and 
at night. Adapted to cases arising from suppression of long- 
standing nasal discharge, especially in scrofulous subjects. 

Lachesis. — Headache characterized by throbbing or beating 
in the temples, drowsiness, and nausea, especially when accom- 
panying menstrual irregularities ; severe pressing pain in the 
forehead, feeling as though it would give way, especially when 
stooping ; pressure in the forehead which increases to a violent 
beating in the evening, with nausea and inclination to vomit ; 



CONGESTIVE HEADACHE. 239 

worse in the evening or after sleeping ; also from motion or 
from stooping. 

Lachnanthes. — Congestive headache, accompanied by burning 
heat, with redness of the face, drowsiness, and ill-humor ; head 
feels greatly enlarged, the head hot, and the body cold ; vertigo, 
with sensation of heat in the chest ; burning of the palms of 
the hands and soles of the feet ; great thirst ; circumscribed 
redness of the cheeks, especialty on the right side. 

Lilium tig. — Fulness in the head, especially in the temples, 
with outward pressure, ameliorated by compression ; blinding 
pain in the forehead, aggravated in the evening, with strange, 
muddled feeling in the head, general weakness, and desire to 
lie down; dull frontal headache; vertigo, with confusion of 
mind, or wild feeling ; aggravated by blowing the nose, or walk- 
ing in the open air. Especially adapted to cases arising from, 
or accompanied by, mental irregularities. 

Lycopodium. — Headache, as if the brain were loose and va- 
cillating, and as if the bones of the head were being driven 
asunder ; throbbing pain near the orbits, from within outward; 
rush of blood to the head early in the morning before rising, 
followed by headache ; aggravated by stooping, walking, and 
by mental exertion ; ameliorated by lying down, or by being 
in the open air. 

Magnesia carb. — Congestive headache, with throbbing in the 
forehead ; rush of blood to the head, especially when smoking; 
heat in the head and hands, w r ith redness of the face, alternat- 
ing with paleness; mental dulness ; vertigo; w T orse towards 
evening, or when smoking. 

Mercurius cor. — Violent rush of blood to the head, severe pain 
in the forehead and temples, and burning of the cheeks; face 
flushed, with burning in the eyes; heaviness of the head, with 
depression of spirits ; profuse prespiration on the forehead ; 
unquenchable thirst; aggravation at night, and also when 
stooping. 

Natrium sulph. — Headache characterized by cerebral conges- 
tion, with sense of fulness ; pressure in and through the head ; 
heat in the top of the head ; heaviness of the head, with epis- 
taxis, not relieved by the bleeding ; vertigo, with heat extend- 



240 INTRACRANIAL DISEASES. 

ing from the body to the head, relieved on the appearance of 
perspiration ; headache, causing heat and sweat, the latter re- 
lieved by motion, but not the headache; eyes sensitive to light ; 
dulness of the mind, and depression of spirits ; headache aggra- 
vated by motion, stooping, and mental exertion. The attacks 
are periodical, occurring during the menses ; menses late and 
scanty. 

Xaja. — Dull pains in the head, especially in the forehead and 
temples; heaviness over the eyes; dryness of the throat; ach- 
ing, throbbing pain about the orbit, followed by vomiting; 
pain extending from sinciput to back of the head ; congestive 
headache arising from organic disease of the heart ; cardiac 
hypertrophy. 

Nitric acid. — Headache caused by cerebral congestion ; heat 
in the head, with throbbing in the temples ; heaviness'and 
dulness of the head, with nausea ; sensitive to noise; worse at 
night, better on lying down. 

Nux worn. — Heaviness of the head, especially when moving 
the eyes or thinking, with sensation as if the skull would split ; 
congestive headache with nausea and vomiting, worse from 
coughing and stooping : headache caused or aggravated by 
thinking or studying, feeling as if the head would burst open; 
vertigo, with pain in the forehead, heat and redness of the face^ 
determination of blood to the head, and constipation; aggra- 
vated by motion, stooping, coughing, thinking, light, noise, 
eating, or drinking coffee. Especially suitable for the seden- 
tary, the intemperate, and those troubled with piles. 

Opium. — Extreme drowsiness, with great heaviness of the 
head ; tendency of blood to the head with constipation, espe- 
cially in elderly persons ; throbbing, beating pains in the 
head, especially in the temples ; headache, worse on moving 
the eyes; vertigo, with dulness of the head and drowsiness: 
red, bloated face, with red, glistening, and projecting eyeballs. 
Especially suited to recent cases in old people, or where the 
symptoms have set in suddenly, with great depression of the 
vital power. 

Phosphorus. — Chronic congestive headache, attended with 
burning and throbbing pains, especially in the occiput ; burn- 



CONGESTIVE HEADACHE. 241 

ing pain in the forehead, with throbbing in the temples ; dull, 
aching pain in the forehead, better in the open air: headache 
accompanying softening of the brain, and attended by weak- 
ness, numbness and formication of the limbs, vertigo, and slow 
answering of questions; head dizzy, heavy, and painful, with 
confusion of mind : general debility resulting from sexual 
abuse, or loss of animal fluids ; aggravated by music, violent 
motion, mental exercise, and by washing in cold water. 

Phosphoric acid. — Violent pressive headache, especially in the 
forehead; stupefying headache with somnolency ; school-girls' 
headache, resulting from brain-fag ; aggravated by the least 
noise, even music; also by shaking the head, and by grief. 
Particularly suited to those persons who have become debili- 
tated by acute diseases, loss of animal fluids, or protracted 
sorrow. 

Psorinum. — Rush of blood to the head, with redness and 
heat of the face ; pressive pain in the forehead, as if the brain 
was too large for the skull ; throbbing, hammering pain in 
the head, caused by mental labor; fulness in the top of the 
head, as if the brain would burst out; headache, with the 
sensation as if the eyes were being pressed out of their orbits; 
headaches caused by repelled eruptions; also chronic head- 
aches which have resisted other indicated remedies, or where 
there is a psoric taint of the system. 

Pulsatilla. — Throbbing, pressing headache, especially when 
caused by anaemia, or by mental exertion, and relieved by 
pressure ; also where there are menstrual irregularities, or 
where the headache is the result of excessive study, rich, fat 
food, abuse of coffee, chamomile tea, quinine, alcoholic stimu- 
lants, or mercury ; worse in the evening, or in a close, warm, 
room; better in the open air, or by bandaging the head. 

Sanguinaria. — Headache attended by rush of blood to the 
head, whizzing in the ears, and transitory feeling of heat, fol- 
lowed by nausea or vomiting; headache as if the head would 
burst, or as though the eyes would be pressed out ; pain most 
severe in the forehead and temples; pain begins in the morn- 
ing, increases during the day, and lasts until evening, passing 
off with a free flow of light-colored urine ; aggravated by 
16 



242 INTRACRANIAL DISEASES. 

motion, light, noise, and touch ; ameliorated by hard pressure, 
quiet, and sleep. 

Sepia. — Pulsating headache in the back of the head, worse 
from the least motion ; violent pressive headache, as though 
the head would burst ; surging sensation in the forehead, like 
waves of pain welling up and beating against the frontal 
bone; headache caused by portal congestion, or by derange- 
ment of the digestive or female sexual system; chronic con- 
gestive headache, with sensitiveness to light, and dropping 
of the upper lids ; aggravated by motion ; ameliorated by rest, 
darkness, and sleep. 

Silicea. — Determination of blood to the head, with hot cheeks, 
and slight burning in the soles of the feet; pulsating, beating 
headache, most violent in the forehead and top of the head, 
with chilliness ; severe pressive headache, extending from the 
occiput to the forehead, causing an aching in the eyeballs, 
which are sore and painful when revolving ; worse from noise, 
motion, and light; better from heat, but not from pressure; 
better also from rest, darkness, and sleep. 

Spongia. — Headache as if the head would burst, especially 
in the forehead and vertex; rush of blood to the head, with 
throbbing and pressure in the forehead ; vertigo at night, or 
when awaking, with nausea ; anxious oppression in the region 
of the heart; dull headache, caused by entering a warm room 
from the open air; aggravated by lying with the head low. 

Stramonium. — Congestive headache, beginning in the morn- 
ing, increasing until noon, and gradually decreasing until 
evening ; headache accompanied by heat, face bloated and 
turgid, with pulsations in the vertex ; sensation of heat in the 
head, especially in the vertex, with great dulness; vertigo, 
especially when walking in the dark ; ameliorated by warmth, 
and by lying quiet, 

Sulphur. — Headache caused by rush of blood to the head, 
and attended by roaring in the ears, heat and redness of the 
face, and cold feet; throbbing headache, especially at night; 
dull, pressive, stupefying headache, with tired and tight feel- 
ing in the brain, especially after severe mental exertion; head- 
ache from abdominal plethora, or when caused by suppressed 



NERVOUS HEADACHE. 243 

eruptions, abuse of spirits, or haemorrhoids; aggravated by 
motion, coughing, stooping, eating, cold weather, and the open 
air; ameliorated by warmth and pressure. 

Theridion. — Violent throbbing headache, extending from the 
forehead to the occiput; throbbing pain in the forehead, with 
nausea ; worse on rising, from lying, and from the least noise; 
vertigo, with flickering before the eyes; disposition to faint 
after every exertion. 

Veratrum vir. — Headache, with fulness of the head, and 
throbbing of the arteries ; face flushed, burning in the head, 
and feeling as though the head would burst open; severe 
frontal headache, with vomiting; headache causing mental 
confusion and loss of memory; vertigo, with cold sweat on 
the forehead, sudden fainting, and collapse ; anguish and fear 
of death ; amelioration toward evening. 

2. Nervous Headache. 

We shall include under this head every form of headache 
of nervous origin, instead of simply confining it, as is generally 
done, to that particular variety known as hemicrania, or me- 
grim. ^The term "sick headache," by which nervous head- 
aches are commonly known, though more expressive, is per- 
haps too general and comprehensive, as it is sometimes made 
to include several secondary affections, such as the headache 
associated with so-called bilious attacks, the headache which 
follows a debauch, and that which accompanies acute diseases, 
such as fevers, albuminuria, apoplexy, etc. Nervous head- 
aches, therefore, it will be seen, are not only of nervous origin, 
but they are primary, not secondary affections, and are due, 
probably, to nervous exhaustion, or to the idiosyncrasy of the 
patient. 

Nervous headaches generally set in early in the morning, 
on rising. The attack is characterized by a severe, deep-seated 
headache, often limited to one side of the head (hemicrania), or 
to one spot, as the temple, forehead, over the eyes, etc. The 
pain is generally increased by movement, strong light, noise, 
or any kind of mental exercise or perturbation. The patient 



244 INTRACRANIAL DISEASES. 

usually suffers more or less from glimmering before the eyes, 
giddiness, swimming in the head, and throbbing in the tem- 
ples; and is generally greatly depressed, pale, dark around 
the eyes, and looks and feels very ill. The attack is usually 
complicated with certain gastric symptoms, such as a coated 
tongue, clammy mouth, anorexia, nausea and vomiting, or 
rather retching, which is often very severe and persistent. 
These symptoms are not necessarily, nor even ordinarily, con- 
nected with a disordered state of the digestive apparatus,- but 
are secondary to the nervous trouble, whatever it may be, that 
causes the headache. 

The chief predisposing cause of this form of headache, is the 
age, sex, and idiosyncrasy of the patient, especially the latter. 
This disease belongs emphatically to the. nervous temperament, 
w 7 hich is often hereditary, or runs in families. It occurs most 
frequently in females, and between the ages of ten and twenty- 
five. As age advances, the attacks usually become less and 
less frequent until the age of fifty or sixty, when they die out. 
In women they commonly cease at the change of life. 

Whatever weakens or deranges the nervous system may also 
act as a predisposing cause, as the excessive use of tea and 
coffee, unhealthy occupations, malaria, a sedentary life, etc. 

The exciting causes are equally numerous and varied. The 
predisposed are very liable to have an attack whenever a pow- 
erful impression is made upon the nervous system by fright, 
sudden or loud noises, storms of wind, thunder and lightning, 
and even extremes of temperature. Nervous exhaustion, also, 
— whether produced by fatigue, worry, family matters, the 
pressure of business, grief, over-nursing, loss of animal fluids, 
self-abuse, deprivation of food or of sleep, or in any other way 
— is a very common exciting cause, producing what is some- 
times termed "asthenic headache," which is. but another name 
for this protean disorder. 

Special Indications. — Acetic acid. — Nervous headaches resulting 
from nervous excitement, chronic gastric irritation, or the 
abuse of narcotic stimulants; giddiness, with or without symp- 
toms of cerebral congestion ; heaviness of the head, with sense 



NERVOUS HEADACHE. 245 

of intoxication ; severe paroxysmal headache, attended with 
dull, aching pains in the frontal regions and vertex; disten- 
tion of the temporal blood-vessels; confusion of mind; vomit- 
ing soon after eating ; aggravated by nervous excitement. 

Aconite. — Nervous headache, with violent pain over the left 
eye, and attended by nausea and vomiting ; giddiness when 
stooping, looking up, or rising from a seat, with nausea; fear 
and anxiety, with great nervous excitability ; gets desperate 
and says she cannot bear the pains ; bitter, greenish vomiting, 
with anxiety ; aggravation by motion, light, noise, and rising 
from a recumbent position. 

Agaricus. — Nervous headaches with semilateral pains ; dull 
headache in the frontal region ; must move the head constantly 
to and fro, and close the eyes; twitching in the skin of the fore- 
head above the right eye ; vertigo and confusion of the head, 
as if intoxicated ; sensation of coldness on right side of fore- 
head, though warm to the touch ; aggravated in the morning, 
and by the heat of the sun ; ameliorated by gentle movements 
of head or body. 

Agnus cast. — Nervous headaches characterized by tearing 
pains above the right eye and temple, attended with soreness 
to the touch, increased by motion, aggravated in the evening, 
and lasting two or three days ; tearing and chilliness in the 
scalp, which, however, is warm to the touch ; headache in the 
vertex which is relieved by looking to one point ; food dis- 
agrees, and causes a feeling of nausea in the pit of the stomach ; 
worse from motion, and in the evening. Especially suited to 
nervous headaches caused by sexual excesses, spermatorrhoea, 
or nervous debility. 

Ailanthus. — Nervous headache characterized by darting pains 
in the temples and occiput, with vertigo and nausea ; severe 
headache, with confusion of ideas, and giddiness; wild looking 
eyes, with intolerance of light ; suitable for nervous, sensitive 
people, especially those troubled with vertigo when stooping. 

Anacardium. — Constrictive nervous headache in the frontal 
region, with very irritable mood ; pain increases hourly ; mo- 
mentarily relieved by hard pressure, finally whole head 
affected ; pains from without inward, spreading from the fore- 



24G INTRACRANIAL DISEASES. 

Lead over the whole head; vertigo when stooping: nausea 
with retching soon after drinking cold water; internal chilli- 
ness even in a warm room; aggravated by motion, bending 
the head backward, and after eating; ameliorated in the even- 
ing, in bed. 

Apis mel. — Constant pressive pain around and above the 
eyes, with dizziness, and confusion of the head; dull, heavy, 
tensive headache over the eyes, with pain through the orbits ; 
neuralgic pain in the left temple; nervous, restless, and irri- 
table disposition ; aggravated by motion or stooping, and only 
temporarily benefited by hard pressure. 

Argentum met. — Deep left-sided headache, at first slightly 
drawing, gradually becoming more violent, and at last culmi- 
nating in a raging pain as if a nerve was being torn, ceasing 
suddenly; feels suddenly giddy, with a mist before the eyes; 
anxious, restless, and irritable mood ; aggravation at noon, 
also from pressure and contact. 

Argentum nit. — Hemicrania, with pressive, screwing, throb- 
bing pain in one frontal protuberance and temple; violent 
pressive pain in the forehead, commencing over the eyes, and 
spreading upward to the vertex; almost constant boring- 
cutting pains in the forehead, vertex, temples, and face; head- 
ache accompanied by chilliness, or by an increased heat of the 
body; giddiness as if intoxicated; ameliorated by bandaging 
the head. 

Arnica. — Xervous headaches characterized by pressive-draw- 
ing pains over the eyes and towards the temples, with a feel- 
ing as though the skin of the forehead was sj3asmodically 
contracted; pains over one eye, with compression in the fore- 
head, and greenish vomiting; pain as if a knife was drawn 
through the head from the left side, immediately followed by 
internal coldness of the head ; sensation of a nail being thrust 
into the temple, followed by faintness; vertigo, with nausea 
and obscuration of sight ; moving the head causes stitches in 
it ; worse in the morning, and on rising or sitting up. 

Arsenicum. — Periodical semilateral headaches, characterized 
by beating pains with nausea, buzzing in the ears, and vomit- 
ing; worse after eating, in the morning, or in the evening, or 



NERVOUS HEADACHE. 247 

at night in bed ; patient weeps and moans with the pain, 
which sometimes becomes maddening ; severe and exhausting 
pain over the left eye, ameliorated by warm applications, or by 
wrapping the head warmly ; burning intermittent pains, hav- 
ing a tendency to periodicity, with small pulse and cold skin, 
worse from continuous applications of cold water ; paroxysms 
of very severe hemicrania, with great weakness and icy-cold 
feeling in the scalp; oedema of the head or face, the parts 
having a natural color; excessive thirst, nausea, and vomiting 
or retching; great anxiety, restlessness, and weakness; aggra- 
vated by eating, motion, rising up in bed, light, and noise ; 
ameliorated by warmth, and by wrapping up the head warmly. 

Asafoetida. — Nervous headaches occurring in weak, nervous, 
and very sensitive persons, especially women; semilateral 
headaches on either side, particularly the left ; crampy pain 
in the forehead, above the eyebrows ; pain as if a nail was 
being driven into the head; involuntary muscular twitchings; 
hysterical restlessness and anxiety. 

Asarum. — Pain of a contractive nature in the forehead and 
temples, with watering and burning of the eyes ; headache in 
the left side of the forehead, with dizziness; vomiting of a 
small quantity of a greenish, somewhat sour fluid, with great 
straining; after vomiting, relief of the headache symptoms; 
great nervous, irritation, with alternate flashes of heat and 
coldness; aggravated by motion or shaking the head; ameli- 
orated by sitting, vomiting, or walking in the open air. 

Asdepias syr. — Violent headache between the eyes, with a 
sense of constriction across the forehead; sharp, cutting pain 
from one temple to the other, with weak pulse and cool skin ; 
nervous headache followed by profuse diuresis; violent head- 
ache attended by excessive nausea. 

Atropine. — Periodical nervous headaches, coming on sud- 
denly, increasing rapidly, and finally causing blindness and 
delirium; sharp neuralgic pains in and about the eyes; vertigo 
on rising in the morning; sticking pains over the eyes on 
every motion, especially on stepping; right side most fre- 
quently affected ; a valuable substitute for Belladonna, espe- 
cially when the latter has been used unsuccessfully in cases 
where it is indicated. 



248 INTRACRANIAL DISEASES. 

Aurum. — Hernicrania returning every three or four days, 
with burning, beating, and stitching pains in one side of the 
forehead, with nausea and vomiting; very despondent, and 
disposed to commit suicide; easily angered and disposed to 
quarrel; pains worse from motion, and on being touched. 

Belladonna. — Nervous headaches, of a semi lateral character, 
affecting especially the right side; the pains are of a boring, 
cutting, tearing, and shooting character, worse on the right 
side and in the forehead ; aggravated by movement, espe- 
cially of the eyes, and by currents of air, the recumbent posture, 
and warmth of the bed ; aggravated also by light, shock, noise, 
or contact; ameliorated by lying down, and by strong pressure 
on the forehead. 

Calcarea carb. — Hernicrania, with inclination to vomit ; tear- 
ing pains on the right side of the forehead ; frequent one-sided 
headache, with eructations; icy-coldness of the scalp, which is 
nevertheless sensitive to the touch ; aggravated by movement, 
and by mental exertion; ameliorated by tight bandaging, 
closing the eyes, vomiting, or by lying down. 

Caulophyllum. — Neuralgic headaches dependent on uterine 
irritation or disturbance ; sensation of pressure over or behind 
the eyes, especially the left, with dimness of vision ; aggra- 
vated by stooping, light, noise, and fright ; worse also in the 
afternoon. 

Causticum. — Nervous headache, with tension of the scalp 
across the forehead and temples ; pains moving forward from 
the vertex in paroxysms, with vertigo and nausea ; headache 
associated with neuralgia of the left side of the face; vertigo 
with loss of consciousness on looking up ; sudden blindness, 
with a sensation of a film before the eyes ; giddiness, with a 
feeling of intoxication ; aggravated by shaking the head, 
stooping, looking up, reading, and in the evening. 

Chamomilla. — Headache increasing and decreasing, espe- 
cially on the right side of the head, with dull, sticking pains, 
which sometimes extend from the temples and forehead to the 
occiput like electric sparks ; the pains are of a pressing, sting- 
ing, 'tearing, or sticking character, frequently recurring, and 
affect especially the left temple and forehead, or the region in 



NERVOUS HEADACHE. 249 

and around the eye ; one-sided drawing headache; wandering 
pains in the temples, worse at the commencement; worse in 
the evening, from stooping, and from mental exertion. 

Chlorahnn. — Headache over both e} T es, extending to the eyes, 
left side worse, with feeling as if the eyes were constricted; 
feeling as if a hot band was drawn across the forehead directly 
over the eyes, with sensation of a burning ring around each 
eye ; severe pain in frontal region over supraorbital ridge, 
aggravated by motion ; dull, heavy, aching pain in the fore- 
head and occiput, aggravated by motion. 

China. — Violent pressive headache, with sense of constric- 
tion, especially in the right side of the forehead and in the 
occiput ; compressive headache, followed by a bruised sensa- 
tion in the sides of the head, aggravated by motion; jerking, 
tearing pains in several parts of the head, worse from motion; 
whole head feels sore and bruised; aggravated by the slightest 
movement, touch, or mental exertion. Especially suited to 
anaemic patients, and those who have become debilitated by 
sexual excesses, loss of animal fluids, or intermittent fever. 

Cicuta. — Semilateral headache, of a pressive character ex- 
ternally; rending, cutting pain in one side of the head; stupe- 
fying headache in the forehead and then in the occiput ; vertigo 
on rising from bed, as if everything was moving from side to 
side; violent shocks through the head, causing it to jerk sud- 
denly; head sinks forward when looking steadily at anything. 

Clmicifuga. — Periodical and remittent headaches; severe 
pains over the left or right eye, extending from the eye and base 
of the brain to the occiput; headache, with severe pain in the 
eyeballs, extending into the forehead, and increased by the 
slightest movement of the head or eyes; aching pains in the 
eyes, extending to different parts of the head; headache, with 
eructations, nausea, and vomiting; dizziness, impaired vision, 
and sensation as if a heavy cloud enveloped the head, pro- 
ducing darkness and confusion; aggravation from movement; 
amelioration from pressure. 

Coca.— Headache in the morning, in the right temple, sharp 
on first rising, and all day when looking up ; the pain darts 
from the temple to the top of the head, leaving a sore feeling 



250 INTRACRANIAL DISEASES. 

behind; headache just above the eyebrows, increased by elevat- 
ing the bead and turning the eves up; dull feeling over the 
whole brow; nervous, restless, and confused; worse in the 
morning, when coughing or blowing the nose, and on looking 
up ; better in the evening, and after eating. 

Cocculus. — Violent headache, in which the patient is unable 
to lie on the back of the head, but is forced to lie on the side ; 
unable to bear the least noise ; noise excites vomiting ; violent 
headache, which compels the patient to sit up, aggravated by 
talking, laughing, noise, or a bright light ; sick headache from 
riding or sailing; headache with vertigo, nausea, and inclina- 
tion to vomit; vertigo as if from intoxication; aggravated by 
eating, drinking, talking, smoking, noises, bright light, and 
cold air; ameliorated by quiet and warmth. 

Coffea. — Semilateral headache, as if a nail were driven into 
the parietal bones, or as if the whole brain were torn and 
bruised; great sensitiveness, with general excitability; worse 
from motion, noise, light, and mental exertion; ameliorated in 
the open air. 

Colocynthis. — Hemicrania, with nausea and vomiting; pain- 
ful tearing through the brain, becoming unbearable when 
moving the upper eyelids; pressing, burning pains in the left 
orbit, temple and nose, and in the upper teeth; severe burning, 
boring pain in the right side of the head; violent pressure in 
the left temple; aching, compressive pains in the forehead, 
with great anguish and restlessness, obliging one to leave the 
bed ; aggravated by moving, stooping, lying, moving the upper 
lids, and being in the open air; ameliorated by pressure and 
touch. 

Crotalus hor. — Headache in the forehead above the eyes, and 
in the temples, worse in the night, with nausea and bilious 
vomiting; is obliged to lie down; severe frontal headache, with 
delirium and coma; tremulous weakness all over, as if from 
some apprehended evil; ameliorated by walking in the open 
air. 

Formica. — Nervous, sick headache, with shooting, neuralgic 
pains in the forehead and temple; headache in the left forepart 
of the head and temples, extending back to the occiput, every 



NERVOUS HEADACHE. 251 

day earlier, with a sore pain over the eye, beginning gradually, 
increasing and extending with a cutting pain into the ear; 
headache with crackling in the left ear, followed by pain in 
left temple, then in vertex, with nausea, and abating of pain 
in the forehead ; worse in the afternoon, when stooping, when 
washing in cold water, and from coffee; better from combing 
the hair. 

Gelsemium. — Nervous, remittent, and intermittent headaches, 
with pain over the eyes, across the forehead, and in the tem- 
ples, accompanied by a slight nausea, and slightly mitigated 
by shaking the head ; periodic orbital neuralgia, commencing 
every day at the same hour ; double vision, dimness of sight, 
and vertigo; aggravated by having anything around the 
head ; ameliorated by bending the head forward, and by shak- 
ing it. 

Glonoin. — Hemicrania attended by hemiopia, sees half 
light and half dark ; severe pain in the forehead, with throb- 
bing in the temples; headache beginning with the warm 
weather, lasting all summer, and increasing and decreasing 
every day with the sun ; nausea, retching, and vomiting, with 
great nervous prostration ; pale face, faintness, and loss of 
consciousness ; aggravated by moving, stooping, shaking the 
head, mental exertion, and atmospheric heat; ameliorated in 
the open air, by fanning, and by uncovering. 

Graphites. — Semilateral headache early in the morning, with 
inclination to vomit ; violent headache, with eructations and 
nausea; vertigo during and after stooping, lasting several 
minutes, with nausea ; headache early in the morning on 
waking, also after eating, or when moving the head. 

Hydrastis. — Headache of a nervous, gastric character, with 
sharp, cutting pains in the temples and over the eyes, more 
over the left, better from pressing with the hand; severe frontal 
headache, with soreness of the scalp; face pale, worn, and 
w T eary looking ; fainting turns, with loss of appetite. 

Hyoscyamus. — Nervous headache, with pressing, stupefying 
pain in the forehead ; pressure in the left side of the forehead, 
changing to shooting; constrictive, stupefying pain in the 
upper part of the forehead, and general malaise, alternating 



252 INTRACRANIAL DISEASES. 

with freedom from all pain ; sleeplessness from nervous irri- 
tation; twitching of the muscles of the eyes, eyelids, and face; 
worse after eating, and after becoming cold; better from mo- 
tion, heat, and bending the head forward. 

Ignatia. — Semilateral headache, with nausea, but without 
vomiting; pain frequently begins behind the mastoid process 
or in the ear, and runs up the side of the head, or back to 
the occipital region, leaving a stiffness in the back of the neck ; 
pressive-drawing pain above the right orbit, and at the root 
of the nose, renewed by stooping low down ; jerking headache, 
aggravated by raising the eyes ; pain in the centre of the fore- 
head, ameliorated by bending the head forward ; dull head- 
ache, confined to the right half of the forehead, involving the 
right eye, which is very sensitive to the light; aggravated by 
smoking, coffee, stooping, moving or raising the eyes, mental 
exertion, noise, light, and walking in the open air; amelio- 
rated by lying on the back, or on the painful side. 

Ipecacuanha. — Semilateral headache, with nausea and vomit- 
ing ; short attacks of fine stinging pains in the head, increas- 
ing to aching; stinging headache, with heaviness and drowsi- 
ness; headache as if the brain was bruised, extending to the 
scalp and nose, with nausea and vomiting; aggravated by 
moving the head, and by stooping; ameliorated out of doors. 

Iris vers. — Sick headaches, beginning with a mist before the 
eyes, the pains being of a dull, heavy, or shooting character, 
in the forehead, accompanied with nausea, vomiting, and 
depression of spirits; tired, aching headache, with violent 
pains over the eyes, in the supraorbital ridge, occurring on 
either side, but only on one side at a time ; paroxysms of pain 
followed by copious emissions of limpid urine and by vomiting, 
with great distress in the epigastrium ; aggravated by violent 
motion, coughing, sneezing, and cold air; ameliorated by con- 
tinuous gentle movements. 

Natrum mur. — Right-sided headache, coming on at 10 a.m., 
with dizziness, dull, heavy pains, glimmering before the eyes, 
fainting and sinking at the pit of the stomach, better in the 
open air; headache beginning in the morning, increasing till 
noon, and going off with the sun; pains in and over the right 



NERVOUS HEADACHE. 253 

eye, lasting until sundown; cannot bear any kind of light; 
pain like a nail driven into the left side of the head ; stitching, 
pressing, and throbbing pains in various parts of the head, 
attended with nausea and vomiting; periodic vertigo, with 
eructations and nausea; constant chilliness and coldness; 
aggravated by moving the head and eyes, by mental exertion, 
natural or artificial light, and warmth; ameliorated by gentle 
exercise, compression, and lying clown. 

Nux vom. — Hemicrania beginning in the morning, increas- 
ing through the day, and growing milder or going off in the 
evening ; sick headache, brought on by coffee, wine, sedentary 
habits, or severe mental exercise ; accompanied by dimness of 
vision, sour bitter vomiting, and constipation ; aggravated by 
noise, light, eating, and the open air; ameliorated toward 
evening, by covering the head up warmly, and by keeping 
quiet. 

Petroleum. — Frontal headache, worse while the nausea con- 
tinues ; pain extending from the back to the front of the head 
and the eyes, with transitory blindness; stitches in the head, 
accompanied by pressure and nausea; scalp very sore to the 
touch, followed by numbness, worse mornings and on becom- 
ing heated ; rapid appearance and disappearance of the symp- 
toms; aggravated by mental exertion, nausea, and rising from 
a recumbent position, which is attended with vertigo. 

Phosphorus. — Sick headache, with pulsations and burning, 
mostly in the forehead, accompanied by nausea and vomiting; 
headache over the left eye, with burning in the forehead; dull 
pain in the whole forehead, with vertigo; hemicrania, with 
pain and swelling in the forehead, which is greatly aggravated 
by being touched ; headache every other day ; aggravated by 
turning the head, stooping, eating, mental exertion, violent 
motion, or being in a warm room; ameliorated by cold wash- 
ing, and the open air. 

Platina. — Neuralgic headaches, occurring in sensitive, ner- 
vous women, with violent pressing, or cramp-like, constrictive 
pains in the forehead, commencing light, increasing till 
violent, and ending as they began; cramping pain from with- 
out inward, with heat and redness of the face, restlessness, 



254 INTRACRANIAL DISEASES. 

roaring in the head, worse from resting, or when stooping; 
numb feeling in the brain ; vertigo when sitting, or when 
going down stairs; better from motion, or when in the fresh 
air. 

Pulsatilla. — Semilateral sick headache, with tearing pains, 
stitches, shocks, vertigo, and desire to vomit ; stupefying head- 
ache, with running chills, and humming in the head, worse 
lying or sitting quietly, or in the cold ; vertigo especially 
while sitting, as if intoxicated; aggravated in the evening, 
from raising the eyes, and when in a close, warm room ; amelio- 
rated in the open air, and by bandaging the head. 

Rhus rad. — Semilateral pain in the temples; dull and con- 
tinued pain in the forehead and above the eyes; quotidian 
periodical headache; vertigo and confusion of head, with 
momentary loss of consciousness ; wandering pains in various 
parts of the body; pains and headache are sharper when lying 
down ; relieved when in the open air. 

Rhus tox. — Headache, with tearing, stitching pains extend- 
ing to the ears, nose, face, and jaws ; scalp sensitive, better on 
the side laid upon, worse from warmth of bed. touch, and 
combing the hair ; vertigo and dulness, as though intoxicated ; 
stupefaction, with tingling in the head and pains in the limbs, 
better from motion ; aggravated by chagrin, warmth of bed, 
and lying down ; ameliorated bv bending the head forward, 
and by motion. 

Sangv/inavia. — Sick headache, the attacks occurring periodi- 
cally : begins in the occiput, spreads upward, and settles over 
the right eye, with nausea and vomiting ; has to be in the 
dark and lie perfectly quiet ; violent pain over the upper por- 
tion of the whole left side of the head, especially in the eye; 
pains begin in the morning, increase during the day, and last 
until evening ; soreness of the scalp in spots, especially in the 
temporal regions ; lancinating, throbbing pains through the 
brain, involving the forehead and top of the head in particu- 
lar, but most severe in the right side, followed by chills, nausea, 
and vomiting of food or bile, forcing the patient to lie down 
and remain perfectly quiet ; aggravated by motion, and only 
relieved by sleep ; neuralgia in and over the right eye ; vertigo, 



XERVOUS HEADACHE. 255 

headache, and long-continued nausea and vomiting ; aggra- 
vated by motion, noise, light, and touch ; ameliorated by dark- 
ness, quiet, pressure, and sleep. 

Scutellaria. — Nervous headache, caused by mental emotion ; 
hemicrania, worse over the right eye, relieved by walking in 
the open air ; tremulousness and muscular twitchings in vari- 
ous parts of the body ; vertigo, with lightness of head ; wake- 
fulness and restlessness at night, with frightful dreams ; urine 
scanty before, and clear and profuse after the headache. 

Sepia. — Hemicrania, with stinging, stitching, or pressive 
pains in the forehead, just over the eyes, worse in the left side, 
with nausea, vomiting, and perspiration ; following the per- 
spiration, headache in the right side of the head and face, but 
not so severe, with a sensation in the forehead as of waves of 
pain welling up and beating against the frontal bone ; stitch- 
ing, boring, hammering headaches over the right eye, or in 
one temple, of such severity as to make her scream, with 
nausea and vomiting ; better from sleep and darkness ; aggra- 
vated by motion and in the evening. 

Silicea. — Hemicrania, with loud cries, nausea, and vomiting, 
followed by obscuration of sight ; severe pain ascending from 
the nape of the neck to the vertex, thence to the supraorbital 
region ; also from the occiput to the eyeball, especially the 
right one ; pains sharp and darting, with a steady aching in 
the eyes, which are sore and painful when revolving ; worse 
from noise, motion, even jarring of the room by a footstep, and 
from light ; relief from heat, but not from pressure ; obstinate 
morning headache, with chilliness and nausea ; sensitiveness 
of the scalp ; frequent sweat about the head ; headache ameli- 
orated by hot compresses, and by wrapping up the head 
warmly. 

Spigelia. — Headache commencing with the rising of the sun, 
reaching its height at noon, and gradually declining until the 
sun sets, appearing thus even in cloudy weather ; pains darting 
from behind forward through the eyeball, with pulsating pains 
in the left temple and over the left eye ; headache, especially 
on the left side, extending to the eyes, face, and teeth ; worse 
from motion, stooping, wind, and fresh air ; better from press- 



256 INTRACRANIAL DISEASES. 

ure, and raising the head ; vertigo, worse in the morning, 
with headache, depriving him of his senses ; eyes look dim, 
upper lid droops ; neuralgic pains involving the eyes, and 
accompanied with a pale face, anxious breathing, palpitation, 
nausea, and vomiting ; patient restless, anxious, and gloomy. 

Sticta. — Sick headache, worse from light and noise, accompa- 
nied by nausea and vomiting nearly to fainting; darting pain 
in the temporal region. 

Stramonium. — Nervous headache, with tearing pain in the 
neck and over the head, shunning the light ; better from 
warmth ; worse on getting up in the morning; spasmodic draw- 
ing in the head and eyes, with grinding of the teeth ; vertigo 
when walking in the dark, both day and night; staring, glis- 
tening eyes, w T ith swollen face ; ameliorated by warmth, and 
by lying still. 

Sulphur. — Periodical sick headache, very weakening, occur- 
ring every one or two weeks; pains lacerating, stupefying, and 
benumbing ; sticking or tearing pains in the forehead or 
temples, worse from eating or stooping, better when moving 
about, or when compressed ; scalp painful to the touch ; pa- 
tient peevish, irritable and quarrelsome ; aggravated by violent 
motion, eating, stooping, sneezing, changes in the weather, and 
mental exertion. 

Tarantula. — Nervous headache, with sharp, penetrating pains ; 
intense headache, with sensation as though thousands of needles 
were pricking into the brain, better from rubbing the head ; 
hyperesthesia of the special senses; ameliorated by rubbing 
and pressure. 

Theridion. — Very severe sick headache, with nausea and 
vomiting, like sea-sickness, and with shaking chills; violent 
frontal headache, extending into the occiput; headache in the 
region of the eyes, with starting in the right eye ; throbbing 
over the left eye and across the forehead, with sick stomach, 
worse on rising, or from the least noise, even footsteps over the 
floor; vertigo, with nausea even to vomiting, also with blind- 
ness; faintness, and flickering before the eyes. 

Thuja. — Nervous headache, with tearing pain in the fore- 
head, temples, and back of the head, worse at night; headache 



SYMPATHETIC HEADACHE. 257 

in the vertex and on the left side, as if something hard, like a 
button or nail, were pressed upon the part ; scalp sensitive to 
the touch, and even to the pressure of the pillow, better if 
rubbed ; violent, burning, tearing, sticking pains, worse in bed; 
vertigo on shutting the eyes, or moving them upward or side- 
ways ; aggravated by sexual excesses, overeating, and at night. 

Veratrum alb. — Nervous, neuralgic, and ordinary sick head- 
ache, with indigestion, nausea, vomiting, pale face, sunken 
features, and stiff neck ; violent pains, driving the patient to 
despair, with great prostration, fainting, and cold sweat, with 
thirst; rertigo, with cold sweat on the forehead; scalp very 
sensitive to the touch ; chronic cases, coming on in the after- 
noon, and lasting through the night; ameliorated towards 
morning. 

Veratrum vir. — Severe frontal headache, with vomiting ; dull 
frontal headache, with sharp neuralgic pains in the right tem- 
ple, near the eye; vertigo, with dilated pupils, and dimness of 
vision; mental confusion, loss of memory, and double vision; 
headache, caused by intense cerebral hyperemia. 

Zincum. — Semilateral headache, with cramp-like or tearing 
pain in the right or left temple ; headache in the forehead and 
occiput, worse in a warm room, after eating, or from drinking 
even a small quantity of wine ; chronic sick headache, with 
weakness of sight ; vertigo, dizziness, nausea, and vomiting of 
bile. Suited to cases arising from brain-fag, anaemia, and men- 
tal and physical exhaustion. 

3. Sympathetic Headache. 

Under this head we include all secondary forms of headache, 
or those caused by external conditions of which the headache 
is symptomatic. AVe shall only treat, however, of the more 
common varieties, such as the arthritic, catarrhal, gastric, hys- 
terical, malarial, menstrual, and rheumatic. These headaches 
are always associated with the special conditions denoted by . 
their respective names, and are therefore easily recognized by 
the symptoms belonging to the primary affections. As the 
headache is purely symptomatic, the disease on which it de- 
17 



258 . INTRACRANIAL DISEASES. 

pends should, of course, receive special attention. At the same 
time, it should be remembered that the primary disease is fre- 
quently aggravated, through sympathy, with the cerebral dis- 
order. This is especially the case with gastric and hysterical 
headaches. Hence, in many cases the headache should be 
treated as though it were the primary disease, and the latter 
the secondary. Happily, homoeopathy, by covering the totality 
of the symptoms, often renders the distinction referred to of 
but little practical importance. It is always well to bear it in 
mind, however, in very stubborn cases. 

General Indications. — Arthritic headache. — Am., Ars., Arm, 
Bell., Bry., Caps., Caust., Cina, Coloc, Ign., Magn., Nit. ac, 
Nux v., Petr., Phos., Puis., Sabin., Sep., Spig., Verat., Zinc. 

Catarrhal headache. — Aeon., All. cep., Alu., Am. mur., Ars., 
Bell., Bry., Caul., Cham., China, Cina, Cimicif., Dulc, Euphras., 
Gels., Gym., Hepar, Ign., Kali bic, Kali carb., Kali iod., Lach., 
Lye, Merc, Mez., Natr. ars., Nat. mur., Nux v., Puis., Ran., 
Samb., Sang., Stil., Stic, Sulph. 

Gastric headache. — Act. ac, Aeon., Ail., Alu., Am. carb., Anac, 
Ant. crud., Apis, Arm, Ars., Asar., Atrop., Bell., Berb., Bism., 
Bry., Calc carb., Calc phos., Caps., Caust., Caul., Carbo veg., 
Cham., Cimicif., Cina, Cocc, Coloc, Eupt, Form., Gamb., Gels., 
Glon., Hyd., Ign., Ip., Ind., Iris, Kali bic, Lach., Lept., Lye, 
Naj., Nux v., Opi., Paris, Phos., Phyt., Plat., Puis., Robin., 
Sang., Sep., Sil., Stic, Sulph., Tabac, Tarant., Verat. 

Hysterical headache. — Arm, Asaf., Bell., Cann. sat., Caps., 
Cham., Cimicif., Cocc, Com, Gels., Hel., Hepar, Hyos., Ign., 
Iris, Lach., Lact., Magn. carb., Magn. mur., Nit. ac, Nux v., 
Phos., Phos. ac, Plat., Rhus tox., Ruta, ScuteL, Sep., Stic, 
Stram., Tarant., Valer., Verat., Zinc, valer. 

Malarial headache. — Ars., Chin., Cedron, Chinin. ars., Chinin. 
sulph., Eucalyp., Eupat. perf., Eupat. purp., Gels., Kali ferro- 
cyan., Rhus., Verat. 

Menstrual headache. — Agnus, Apis, Ars., Bell., Berb., Borax, 
Bov., Brom., Bry., Cact., Calc. carb., Carbo an., Caul., Cham., 
Cimicif., Cocc, Com, Col., Croc, Gels., Goss, Ham., Hel., Hyos., 
Ign , Kali carb., Lach., Lib, Lye, Natr. mur., Nux mosch., Nux 



SYMPATHETIC HEADACHE. 259 

v., Plat., Pals., Sang., Sep., Sil., Stram., Sulph., Thuj., Ust., 
Verat., Zinc. 

Rheumatic headache. — Aeon., Act. spic., Am. mur., Asclep., 
Bell., Berb., Bry., Calc. phos., Caul., Caust. Cham., China, Ciini- 
cif., Coloc, Dulc, Gua., Ign., Kali bic., Kalm., Lach., Led., 
Lye, Magn. mur., Merc, Nit. ac, Nux v., Phos., Phyt,, Pod., 
Puis., Rhus rad., Rhus tox., Sep., Sil., Spig., Stic, Stram., 
Sulph. 

Special Indications. — Aconite. — Headache with fever, especially 
when caused by exposure to cold, suppression of perspiration, 
or currents of air; headache accompanied by coryza, fever, 
roaring in the ears, chilliness, restlessness, and wakefulness ; 
pains of a piercing, throbbing, or stupefying character, aggra- 
vated by noise, light, or motion. Suitable for catarrhal and 
menstrual headaches, especially at the beginning. 

Allium cepa. — Severe catarrhal headache, with coryza ; co- 
pious watery discharge from the nose and eyes; symptoms 
worse in the evening ; better in the open air. 

Aluminum. — Chronic catarrhal headache, especially in scrof- 
ulous subjects; head feels heavy, with oppression in the fore- 
head ; pressive, stupefying pain in the frontal region ; aggra- 
vated by being in a warm room, or by going up stairs, or 
stepping; ameliorated by pressure. 

Anacardium. — Gastric headache caused by indigestion; nau- 
sea with retching soon after drinking cold water; weak diges- 
tion with fulness and distention of the abdomen; symptoms 
disappear after dinner, and reappear two hours afterwards. 

Antimonium crud. — Gastric headache, with aversion to food ; 
tongue coated white; aching of the limbs, nausea, and vomit- 
ing; anorexia, risings, and inclination to vomit; symptoms 
relieved in the open air. 

Asafoetida. — Hysterical headache in the hypersensitive; pains 
of a darting, stitching, jerking character, which sometimes dis- 
appear by the touch, or are transformed into other pains; hy- 
pochondriacal and hysterical restlessness, with anxiety ; ameli- 
orated by walking in the fresh air. 

Argent-am nit. — Gastric headache in nervous persons; head- 



2G0 INTRACRANIAL DISEASES. 

ache is usually attended with chilliness and trembling of the 
body, intense nausea, and vomiting; patient giddy and very 
restless; headache worse in the open air, but better from ban- 
daging the head. 

Arsenicum alb. — Catarrhal, gastric, and malarial headaches, 
especially when they are of an intermittent or periodical char- 
acter, and attended with a burning nausea and the arsenic 
thirst; pains are of a burning, beating, pressive, drawing, or 
throbbing character, and are relieved by warmth, or wrapping 
up the head, or by rubbing; cold water only relieves tempo- 
rarily; sometimes associated with a fluent, burning and exco- 
riating coryza. 

Belladonna. — Catarrhal, gastric, and rheumatic headaches, 
especially in lymphatic or scrofulous subjects; pains are sudden 
in their appearance and disappearance, but last indefinitely; 
are often accompanied by stupefaction and vertigo, with red- 
ness and swelling of the face: aggravated by noise, light, shock, 
or contact; symptoms caused by cerebral congestion. 

Berberis. — Arthritic, menstrual, and rheumatic headaches, es- 
pecially when complicated with hepatic trouble ; pains are of 
a lacerating, darting, tensive, or aching character; face pale, 
with sunken cheeks, and eyes surrounded by a dark bluish or 
blackish circle ; worse from motion, stooping, and in the after- 
noon; better in the open air. 

Bismuth, — Gastric headache complicated with gastralgia; 
pain comes on immediately after eating, and is relieved by 
vomiting; pains chiefly frontal, and aggravated by motion. 

Bovista. — Menstrual headache, characterized by deep-seated 
stupefying pains; putrid, bitter taste, with nausea and empty 
eructations; morning sickness, relieved by eating breakfast; 
aggravated by pressure, and by sitting up. 

Bryonia. — Gastric and rheumatic headaches, especially when 
associated with indigestion, nausea, and vomiting; pains are of 
a throbbing, digging, sticking, burning, or pressing character, 
and may affect any portion of the head; the pain is usually 
associated with soreness, and is aggravated by stooping, or by 
quick motion. 

Calcarea phos. — Gastric and rheumatic headaches, with ml- 



SYMPATHETIC HEADACHE. 261 

ness and pressure in the head, and characterized by vertigo 
when walking or moving; patient is dull, peevish, quarrelsome, 
and forgetful; aggravated by every change in the weather, 
eating, and mental and bodily exertion; ameliorated by cold 
washing. 

Carbo an. — Menstrual headache, chiefly in the forehead and 
vertex; the pains are of a throbbing, pressing, or tearing 
character, accompanied by vertigo, confusion of the senses, 
and sometimes by nausea ; sensation in the forehead as if 
something lay above the eyes, on account of which she could 
not look up ; dimness or blackness of sight, with vertigo and 
nausea when raising the head after stooping; menses too 
early and too long, but not too great, followed by debility and 
prostration. 

Caulophyllum. — Menstrual and rheumatic headaches, char- 
acterized by pressure behind the eyes and dimness of sight ; 
the pains, which are of a contractive, pressive character, are 
paroxysmal or intermitting ; menstrual irregularities, with 
"moth" spots on the forehead; aggravated by stooping, light, 
and noise. 

Causticum. — Arthritic and rheumatic headaches, especially 
where there is a tendency to scrofula ; pains are of a throbbing, 
tearing, and stitching character; chiefly in the top of the 
head, and spreading to the forehead and temples, moving 
forwards in parox} T sms ; accompanied by nausea and vertigo ; 
aggravated by stooping, reading, looking up, and shaking the 
head ; ameliorated in the open air. 

Cedron. — Malarial headaches coming on with clock-like reg- 
ularity; pains are of a shooting character, and are located 
chiefly in the frontal region, often extending to the orbits ; 
when the pains are very severe, the} T are often accompanied 
by palpitation and quickened respiration. 

Chamomilla. — Arthritic and rheumatic headaches, especially 
when attended by vertigo, nausea, and vomiting; headache in 
sensitive, nervous organizations; especially suited to children, 
women, and aged people ; pains of a stinging, stitching, tear- 
ing, and pressing character ; chiefly in the forehead, temples, 
and vertex ; aggravated by mental exertion ; ameliorated by 
motion. 



262 INTRACRANIAL DISEASES. 

Chelidonium. — Bilious headaches, affecting especially the 
right side of the forehead, and the right temple, and accom- 
panied by nausea and bilious vomiting; pain is. of a heavy, 
drawing, and pressing character ; aggravated by motion ; 
ameliorated by rest, pressure, and closing the eyes. 

Cocculus. — Gastric and menstrual headaches, with a feeling 
of emptiness in the head ; violent headache which compels the 
patient to sit up, and is aggravated by talking, laughing, 
noise, and bright lights. 

Colocynthis. — Arthritic and rheumatic headaches of an inter- 
mitting type; pains are of a tearing, aching, drawing, and 
compressive character; are often semilateral, affecting chiefly 
the left side of the head ; and are accompanied with more or 
less restlessness and anguish ; vertigo, with nausea or vomit- 
ing of bitter, yellowish fluid ; aggravated by motion, stooping, 
and bending the head forward ; ameliorated by pressure. 

Crocus. — Menstrual headache, of a pressive, burning, and 
throbbing character, affecting chiefly the forehead, temples, 
and top of the head ; excitable and variable disposition ; 
vertigo, with confusion, and webs before the eyes; headache at 
the change of life, most severe at the time corresponding to 
the monthly periods, lasting two or three days, and even 
during the night. 

Eupatorium perf. — Bilious and malarial headaches, with 
violent shooting and throbbing pains, chiefly in the vertex, 
temples, and occiput ; vomiting of bile, and of whatever has 
been taken into the stomach ; tongue coated white or yellow ; 
attacks generally occur in the morning, between 7 and 9 a.m. ; 
aggravated by heat ; ameliorated by pressure. 

Euphrasia. — Catarrhal headache, accompanied by profuse 
watery coryza; profuse, fluent coryza, with smarting of the 
eyes, lachrymation, and photophobia, or with sneezing and 
discharge of mucus ; headache from cold in the head, with 
running from the eyes and nose. 

Gamboge. — Gastric headache, with compressive and heavy 
pains in the forehead and temples; and accompanied with 
vomiting, purging, and fainting; drowsy, heavy feeling in 
the whole head, with pain in the small of the back ; watery 



SYMPATHETIC HEADACHE. 263 

diarrhoea, with colic and tenesmus ; headache relieved in the 
open air. 

Gelsemium. — Catarrhal and hysterical headaches, appearing 
suddenly with vertigo, dimness of sight and double vision ; 
head feels enlarged, and either too heavy or too light ; head- 
ache accompanied by slight nausea, slightly mitigated by 
shaking the head ; pain in the occiput and back of the neck, 
extending to the shoulders ; also across the forehead and tem- 
ples ; headache relieved by profuse urination. 

Gossypium. — Menstrual headache, with drawing and sting- 
ing pains extending from the temples to the centre of the 
forehead ; nausea, with inclination to vomit ; menses last only 
about twenty-four hours, and are scanty and painful. 

Gymnocladus. — Catarrhal headache, especially during the 
early stage, characterized by fulness, throbbing in the fore- 
head and temples, vertigo, numbness, heat of face, and ex- 
haustion; frequent violent sneezing, originating high up in 
the nose; dizziness, with dimness of sight, nausea, and eruc- 
tation. 

Hydrastis. — Catarrhal headache, especially in debilitated 
subjects, with mucous discharges; myalgic headache in the 
integument of the scalp and muscles of the neck ; pale face, 
with worn and weary appearance ; constant discharge of thick 
white mucus from the nose ; cachetic condition, with loss of 
appetite and fainting turns ; subacute and chronic cases. 

Ipecacuanha. — Gastric headache, commencing with nausea 
and vomiting, or in which the gastric irritation is persistent ; 
stinging, throbbing, lacerating headache, accompanied by 
nausea and vomiting, heaviness of the head, and drowsiness ; 
aggravated by stooping or moving the head ; ameliorated out 
of doors. 

Iris vers. — Bilious and gastric headaches, always beginning 
with a blur before the eyes, with dull, heavy, or shooting and 
throbbing pains in the forehead, accompanied by nausea and 
vomiting, first of watery, sour fluid, then of bile ; paroxysms 
of pain, followed by copious emissions of urine and vomiting, 
with great burning and distress in the stomach. 

Kali bich. — Catarrhal and rheumatic headaches, the former 



264 INTRACRANIAL DISEASES. 

accompanied by ozcena; frontal headache, complicated by a 
chronic catarrhal condition of the nasal and other mucous 
surfaces; aggravated by moving, stooping, or mental exer- 
tion ; ameliorated by hard pressure. 

Kali carb. — Catarrhal headache, especially in aged people 
inclined to obesity; pains are of a sticking character, worse 
when stooping, or moving the head ; better from raising the 
head, and from warmth ; constipation. 

Kali iod. — Catarrhal headache, especially in scrofulous and 
syphilitic subjects; tensive, stinging, shooting, and tearing 
pains in every part of the head, especially the forehead; head- 
ache accompanied with inflammation of the frontal sinuses, 
nose, eyes and throat; swelling of the cervical glands; violent 
sneezing, with running of acrid water from the nose, excoriat- 
ing the skin. 

Lachesis. — Catarrhal, hysterical, menstrual, and rheumatic 
headaches, characterized by throbbing, beating, and lacerating 
pains in the temples, with pressure in the forehead, and 
accompanied by nausea and vomiting; beating headache with 
heat, worse on the vertex and over the eyes ; giddiness, with 
headache, just before the menses; pain in the left ovarian 
region ; ameliorated by lying down. 

Lilium tig: — Menstrual headache, especially in those cases 
where the menstrual irregularity arises from prolapsus or mal- 
position of the uterus, and causing stranguary and ineffectual 
urging to stool; pains in the forehead and temples, with 
vertigo, and depression of spirits ; constant bearing down in 
the lower part of the abdomen, with severe pressure in the 
ovaries, rectum, and anus, with constant desire for stool ; bear- 
ing down pressure in the vagina, as if everything would be 
pressed out; symptoms worse from rising up, and from 
standing. 

Lycopodium. — Gastric, bilious, and rheumatic headaches, 
characterized by great restlessness and disposition to faint; 
pains chiefly of a pressive and lacerating character, affecting 
especially the forehead and temples, and worse in the afternoon. 

Mercurius. — Catarrhal and rheumatic headaches, especially 
when occurring in syphilitic subjects; pains of a burning, 



SYMPATHETIC HEADACHE. 265 

stitching, tearing, and pressing character, accompanied by 
catarrhal affections of the head and throat, and disposed to 
sweat easily ; chronic cases complicated with ozoena, the pain 
extending to the root of the nose and frontal sinuses. 

Mezereum. — Catarrhal headache in scrofulous and syphilitic 
patients; headache extending from the root of the nose into 
the forehead, as if everything would press asunder, with pain 
in the temples when touched ; heat and perspiration on the 
head, with chilliness and coldness of the rest of the body. 

Natrum mur. — Menstrual headache occurring before, during, 
and after the menses, which are either too soon and profuse, 
or scanty and delayed ; disposition sad and gloomy ; awakes 
every morning with a violent headache ; almost constant dull 
headache, especially in the forehead and top of the head. 

Natrum sulph. — Menstrual headache occurring periodically, 
during the menses, every spring, and characterized by ful- 
ness, heat in the vertex, pressure, vertigo, nausea, and vomit- 
ing; menses late and scanty; sad and depressed mood ; worse 
in the forenoon. 

Nux mosch. — Hysterical headache, especially when compli- 
cated with gastric troubles ; throbbing and tearing pains, 
chiefly in the forehead and temples, worse in bad weather, 
before the menses, and during pregnancy ; throbbing, pressing 
pain, confined to small spots, worse in left supraorbital region; 
menses too early and too profuse ; bloating of the stomach and 
abdomen, worse after every unpleasant emotion ; aggravated 
by eating, emotional excitement, menstrual congestion, and 
changes in weather. 

Nux vomica. — Gastric and bilious headaches, attended by 
constipation, and brought on by a debauch, wine, coffee, seden- 
tary habits, or too close mental application ; intense pressing, 
t drawing, stupefying headache, affecting the whole or any part 
of the head, but especially the forehead, with more or less 
dizziness, nausea, and inclination to vomit; aggravated by 
motion, stooping, moving the eyes, noise, light, and mental 
exertion. 

Phosphorus. — Hysterical headache, excited or aggravated by 
anger, chagrin, grief, abuse of stimulants, or excessive mental 



266 INTRACRANIAL DISEASES. 

exertion; dull, burning, or throbbing pains in the forehead or 
temples, often semilateral, and accompanied by nausea or 
vomiting, vertigo, with a tendency to fainting, especially in 
the morning, on rising ; sudden changes of mood, from grave 
to gay, laughing to weeping ; aggravated by stooping, music, 
mental and moral disturbances. 

Phosphoric acid. — Hysterical headache, especially in school 
girls, and those debilitated from sexual and other excesses ; 
pressive, stupefying pains in the forehead and top of the head, 
aggravated by the least noise or jar ; headache from cerebral 
exhaustion, with mental cloudiness ; great physical weakness 
and prostration, accompanied by night-sweats and emaciation ; 
ameliorated by the recumbent position. 

Phytolacca. — Gastric and rheumatic headaches, especially in 
syphilitic subjects ; pains of a sharp, shooting, or dull, heavy 
character, affecting especialty the forehead and temples ; often 
accompanied with vertigo, dimness of vision, and nausea ; gen- 
erally aggravated by damp weather. 

Platina, — Hysterical headache, especially in young girls with 
erotic desires, or who are suffering from amenorrhcea, or from 
profuse menstruation ; pains are of a drawing, crampy charac- 
ter, and affect chiefly the forehead ; face generally red and hot ; 
numb feeling in the brain ; mood variable, sometimes cheer- 
ful, at others depressed ; aggravated by stooping, and by being 
in a warm room ; ameliorated by going into the fresh air. 

Podophyllum. — Gastric, bilious, and rheumatic headaches, 
especialty when produced by torpidity of the liver ; headache 
alternating with diarrhoea ; headache accompanied by bitter 
taste and risings, giddiness, glimmering before the eyes, nausea, 
tendency to bilious vomiting and purging ; symptoms worse 
in the morning ; better from pressure, and from lying quiet in 
the dark. 

Pulsatilla. — Gastric, menstrual, and rheumatic headaches, 
especially when caused by menstrual irregularities, mental ex- 
ertion, fat food, the abuse of coffee or spirits, or from exposure 
to damp, cold weather ; pains may be of almost every variety, 
and are often semilateral ; are generally accompanied by more 
or less vertigo, nausea, and bad taste in the mouth, but with- 



SYMPATHETIC HEADACHE. 267 

out thirst ; worse in bad weather ; better from pressure or ban- 
daging the head, also in the open air. 

Paimex. — Catarrhal headache, with great irritation of the 
larnyx, and soreness behind the sternum ; pains generally dull, 
but sometimes sharp and piercing ; aggravated by motion. 

Sanguinaria. — Gastric and rheumatic headaches, most severe 
on the right side, affecting especially the frontal region and 
temples, and accompanied by nausea and vomiting ; the attacks 
are generally paroxysmal, with more or less chilliness and 
burning in the stomach ; aggravated by motion, light, and 
noise ; ameliorated by darkness, quiet, and sleep. 

Scutellaria. — Hysterical headache, especially when excited by 
mental emotion ; pain worse over the right eye ; ameliorated 
by moving about in the open air ; urine scanty before, and pro- 
fuse after the headache. 

Sepia. — Gastric, hysterical, and rheumatic headaches, espe- 
cially when depending on derangement of the digestive or sex- 
ual systems ; pains generally of a pressive or stinging, stitching 
character, and often one-sided, usually the right ; nausea and 
vomiting, with aversion to all food ; aggravated by motion and 
noise; ameliorated by rest, darkness, and sleep. 

Silicea. — Gastric and rheumatic headaches, especially in 
lymphatic constitutions ; pains pulsating, pressing, or tearing, 
and frequently one-sided ; vibratory sensations in the head, ac- 
companied by nausea and vomiting, frequent cold sweat about 
the head ; aggravated by noise, light, and motion, even the 
slightest jar ; ameliorated by warmth, darkness, and sleep. 

Stillingia. — Catarrhal headache in syphilitic and scrofulous 
constitutions ; dull, heavy, stupefying pains in the frontal re- 
gion ; dizziness, with throbbing in the head ; pains in the head, 
with inflamed and watery eyes, and general soreness of the 
muscles; chronic headache which has been aggravated by 
mercurial treatment. 

Stramonium. — Hysterical and rheumatic headaches, es- 
pecially in young and plethoric persons; swollen face with 
glistening eyes ; vertigo when walking in the dark ; heat and 
pulsations about the vertex, accompanied by faintness and 
loss of sight and hearing ; aggravated by cold ; ameliorated 
by warmth and quiet. 



268 INTRACRANIAL DISEASES. 

Sulphur. — Catarrhal and gastric headaches, especially in 
scrofulous patients ; headache associated with constipation, 
morning diarrhoea, or haemorrhoids; headache from abdominal 
plethora, suppressed eruptions, or mental exertion ; headache 
beginning, increasing, and ending, with the daily course of 
sun ; aggravated by motion, stooping, wet and cold weather, 
heat of the bed, or mental exercise; ameliorated by pressure 
and moderate warmth. 



VERTIGO. 269 



CHAPTER II. 

VERTIGO. 

Perhaps the best definition we have of vertigo is that given 
by Hughlings Jackson, namely, the consciousness of disordered 
locomotor coordination. 

It has long been known that the cerebellum is the chief 
organ concerned in the normal equilibration of the body. 
But numerous experiments upon the optic lobes and pons 
Varolii establish the fact that they, also, are concerned in this 
function ; electrical stimulation of these bodies causing com- 
plex movements of nearly all the muscles of the body, and 
especially of those concerned in progression, and in preserva- 
tion of the normal attitude. These three parts, therefore, may 
be considered as forming the general nervous centre from 
which the power of muscular coordination is derived. For 
it is by means of this combined mechanism that the eyes, the 
head, and the limbs are made to act in harmony, whenever a 
compensatory movement is required to counteract the tendency 
to displacement which occurs whenever the body is in the 
erect position, whether standing or progressing. This is well 
shown by experiments on the cerebellum. For if the anterior 
part of the middle lobe of this organ be destroyed, it causes 
a tendency in the animal to fall forwards ; but it is plain that 
this tendency may be neutralized or prevented by stimulating, 
instead of destroying, this centre, as this induces just such 
muscular movements as would counteract that tendency. So, 
also, destruction of the posterior part of the middle lobe pro- 
duces a tendency to fall backwards, and of the lateral lobes to 
fall sideways, whilst stimulation or excitation of these parts 
excites precisely those muscular actions which are needed to 



270 INTRACRANIAL DISEASES. 

counteract the tendency to fall in these particular directions. 
But the afferent or sensory part of this coordinating mechan- 
ism does not consist alone of the visual apparatus, but also 
includes the auditory and tactile. Experimental researches 
have established the fact that the semicircular canals are con- 
cerned in the function of locomotor coordination ; injury and 
disease of these parts producing a marked and peculiar dis- 
turbance of normal equilibration. The disorder is temporary 
when one side only is injured, but permanent when both sides 
are affected. Flourens has shown, that injury of each canal 
is followed by its own peculiar disturbance, causing the body 
to fall, or to tend to fall, as the case may be, forwards, back- 
wards, or to either side, according to the particular canal 
involved. 

Now, the derangement of any part of the senso-motor appa- 
ratus we have described, may produce vertigo by interrupting 
its power of adjustment. This adjustment, as we have shown, 
is generally effected by contrary or counteracting movements 
to those which give rise to the vertigo. When the movement 
is continued too long to be effectually compensated in this 
manner, as in dancing, whirling, etc , vertigo is the inevitable 
result, and can only subside gradually, as the unequal laby- 
rinthine tension becomes equalized by rest. 

But vertigo is not always, nor even generally, the result of 
exaggerated and prolonged locomotive disturbances. It is 
usually a purely subjective symptom, being, as already defined, 
the consciousness of disturbed locomotor coordination. It is 
often associated with the compensatory movement itself, and 
hence is often confounded with it. This movement, namely, 
reeling and staggering, is not directly caused by the vertigo, 
but is simply the result of the effort made to counteract the 
tendency to fall ; the motion being rendered more or less 
irregular by the disturbance of the coordinating power. That 
this is the true nature of vertigo, is shown by the fact that 
when a movement actually follows a previous sensation of a 
movement which is only apparent, the actual movement is 
always in the direction in which the person felt that he was 
moving before it took place. 



VERTIGO. 271 

Etiology and Pathology. — It is not always easy to deter- 
mine with precision which of the sensory impressions is con- 
cerned in this or that particular case of vertigo. Sometimes the 
impressions are labyrinthine when they appear to be ocular, 
and vice versa. Doubtless in some cases the two causes are 
combined. This is the more probable from the fact that vari- 
ations in labyrinthine tension may be caused by differences in 
the vascular tension of the labyrinthine blood-vessels, and a 
similar case may, and often does, operate in the case of visual 
disturbances. Not only do labyrinthine, visual, and tactile 
disturbances give rise to vertigo, but, as is well known, the 
latter is often caused by derangement of the stomach and other 
viscera. This is easily explained by the close and important 
nervous relations which the labyrinth sustains to these organs. 
For example, the nucleus of the vestibular nerve, which sup- 
plies the semicircular canals, and which is a branch of the 
auditory nerve, is in close relation to the nucleus or internal 
origin of the pneumogastric. Those diseases, also, as well as 
those medicines which cause variations in the labyrinthine 
tension, may give rise to vertigo. 

Varieties. — The principal varieties of vertigo are : 1. The 
Labyrinthine or Auditor}' ; 2. The Ocular ; 3. The Gastric ; 
4. The Nervous ; and 5. The Intracranial. 

1. Labyrinthine or Auditory Vertigo. — This form of vertigo is 
generally known as Meniere's Disease, having been first de- 
scribed by Meniere, in 1861. 

Symptoms. — The disease is generally confined to those 
whose organs of hearing were previously in a sound condition. 
The first symptom to attract the patient's attention is a loud 
noise in the ear. Similar noises, and noises of various kinds, 
may be heard from time to time in the ear, or they may be 
continuous, but the first attack is usually the loudest, or at 
least seems so to the patient. This symptom, which is always 
confined to one ear, is quickly followed by a sense of giddiness, 
in which both the patient's body and all surrounding objects 
appear to be moving in one and the same direction, namely, 
from the affected side. This is generally the case, also, in sub- 
sequent attacks. Not that the movement is always lateral, as 



272 INTRACRANIAL DISEASES. 

respects the patient's body, for it may be from behind forward, 
or toward either side, or it may be rotatory ; but whatever 
course the body may take, or may appear to take, such will be 
the apparent movement of all other visible objects. The same 
sensation may occur when the patient is lying down; the bed, 
room, and everything in it appearing to rise, sink, or revolve, 
as the case may be. If the patient is standing or w r alking, he at 
once begins to reel or stagger, and unless he is so situated that 
he can immediately lay hold of some support, he may be thrown 
violently to the ground. In this case, however, there is no loss 
of consciousness, as when a person falls in a fit. In some cases 
an oscillatory movement of the eyes occurs, but authorities 
differ as to whether it corresponds to the apparent movement 
of the surrounding objects, or the reverse. It is highly prob- 
able, however, that the relative movement is different in differ- 
ent cases. These symptoms are soon followed by nausea, and 
in most cases by vomiting. Almost always the attack is 
attended by more or less shock to the system, manifested by 
pallor of the face, and by a cold skin, which is bedewed by a 
clammy perspiration. As the attack passes off, w T hich gen- 
erally occurs in a few minutes, the tinnitus aurium abates, 
leaving more or less deafness behind. The symptoms of shock 
also subside, but vomiting and vertigo are more persistent, 
lasting in some cases several days. Indeed, occasionally the 
vertigo continues, but in a milder form, from one attack 
to another, which in such cases is marked by paroxysmal 
exacerbations. This condition of constant vertigo, however, 
is not generally reached until after several distinct attacks, 
the intervals between which gradually lessen until a perma- 
nent state of vertigo and deafness is induced. This is a truly 
distressing condition, but yet cures, both therapeutic and spon- 
taneous, sometimes occur, .especially when the labyrinthine 
disturbance is secondary to catarrh of the middle ear, or to 
some other remediable affection of the auditory apparatus. 

Diagnosis. — This is not difficult, provided w T e bear in mind 
that the coexistence of vertigo, tinnitus, and deafness, establish 
the fact that the labyrinth is involved. This may be also con- 
firmed by testing the hearing with a tuning-fork and watch. 



VERTIGO. 273 

To determine whether the disease is primary or secondary, we 
have to consider the presence or absence of certain symptoms. 
Thus, tinnitus and deafness without vertigo indicate an affec- 
tion of the middle ear; the same is true of tinnitus and vertigo 
without deafness. But in order to clear up the diagnosis in 
these cases, it will generally be necessary to test the condition 
of the conducting apparatus, ascertain the permeability of the 
Eustachian tube, and make an otoscopic examination of the 
membratii-tympani, since it is not until this is done that we 
are prepared to estimate the significancy of the syncope, nausea, 
vomiting, and other like indefinite symptoms. 

Prognosis. — The prognosis should be governed by the 
nature of the cause. If this is found to be of a temporary and 
remediable nature, such as altered cerumen, catarrh of the 
middle ear, etc., it will, of course, be favorable; but if the 
vertigo arises from disease of the labyrinth, the attack is not 
only liable to be repeated, but to leave behind it a greater or 
less degree of permanent vertigo and deafness. 

2. Ocular Vertigo. — Ocular vertigo is that form of dizziness, 
confusion of sight, and swimming in the head, which results 
from certain kinds of ocular disorders. Any disease of the eye 
which causes the patient to see double will give rise to this 
form of vertigo, and even to reeling. This is occasioned, not 
by the diplopia or double vision, but by the erroneous pro- 
jection, as it is called, which the squinting or paralyzed eye 
forms of external objects. This causes confusion of sight; and 
if the effort at rectification is not successful, or is long-con- 
tinued, it is liable to produce well-marked vertigo, and even 
nausea. Moreover, the strain which this constant effort at 
optical adjustment produces, leads to exhaustion of the ocular 
muscles, nervous irritation, and vascular congestion — in short, 
the condition known as asthenopia. This condition of the eye 
may be brought about in various wavs. One of the most fre- 
quent is met with in myopia, or short-sightedness. In this 
case, owing to the extreme convergence of the optic axes neces- 
sary for distinct vision, there is actual insufficiency of the in- 
ternal recti muscles. The constant forcible strain to which 
they are subjected in the attempt to direct the axes of vision 
18 



274 INTRACRANIAL DISEASES. 

upon very near objects, which is the only position in which 
the conformation of the eye will permit of their being distinctly 
seen, soon fatigues, and finally exhausts them, producing what 
is called "muscular asthenopia." Another frequent cause of 
ocular vertigo is an absolute or relative deficiency of energy 
in the ciliary muscle, or muscle of accommodation. As the 
fatigued muscle gradually relaxes, after having been unduly 
exercised, objects become less and less distinct, the effort at ac- 
commodation is proportionably increased, the retina itself soon 
becomes more or less exhausted by the steady contest with in- 
distinct images, and thenceforth objects appear to swim before 
the eyes. This form of ocular vertigo is known as " accommo- 
dative asthenopia." Muscular and accommodative asthenopia 
are not confined to myopia; on the contrary, the greater num- 
ber of cases are associated with hypermetropia. But while the 
immediate cause of ocular vertigo is overburdening of one or 
more of the ocular muscles, the muscular insufficiency is often 
congenital, and sometimes hereditary. Moreover, it is very 
often acquired, and .then it generally results from exhausting 
diseases, such as fevers, diphtheria, anaemia, etc. 

3. Grastric Vertigo. — Gastric vertigo is not an uncommon 
affection, being met with in various kinds of stomach trouble, 
both functional and organic. It is sometimes caused by indi- 
gestion, or by overloading the stomach ; but it also occurs when 
the stomach is empty. In these cases we usually have a 
variety of gastric symptoms, such as pain in the stomach, 
heartburn, a feeling of distention, eructations, and even vomit- 
ing. Pains may also be felt in the chest, the hypochondria, 
or the epigastric region. The bowels may or may not be dis- 
turbed. The vertigo generally sets in suddenly, with swim- 
ming in the head, reeling, and a disposition to faint. The 
patient, without loosing consciousness, sees everything turning 
black and apparently revolving around him; his gait becomes 
tottering, and, unless he is promptly supported, will probably 
fall to the ground. Vomiting now occurs, and is often trouble- 
some, especially if it has been preceded by headache, nausea, 
palpitations, and other evidences of a more general nervous 
derangement. Occasionally the gastric symptoms are less 



VERTIGO. 275 

pronounced, being masked, as it were, by the cerebral symp- 
toms ; but as treatment directed to the stomach relieves the 
vertigo, we may safely conclude that the trouble is of gastric 
origin. If strongly predisposed to gastric derangement, very 
slight causes may be sufficient to excite an attack, such as 
looking at bright objects, or rapidly moving ones ; but such 
cases may also occur spontaneously, and, moreover, are not 
strictly cases of gastric vertigo, although the gastric symptoms 
predominate. 

Diagnosis. — As gastric symptoms are sometimes associated 
with auditory vertigo, and may even be so prominent as to 
mask the aural affection, it is important, in case there is any 
doubt about the nature of the affection, to institute a thorough 
examination of the ears. The presence or absence of deafness, 
and of the physical signs of aural disease, will speedily settle 
the question as to whether the case is one of auditory, or some 
other form of vertigo. 

4. Nervous Vertigo. — We include under this head not only 
the vertigo frequently met with in people of weak nerves ; the 
vertigo sometimes caused by the immoderate use of tea, alcohol, 
tobacco, and other narcotic stimulants ; and the vertigo asso- 
ciated with nervous exhaustion and depression, but that also 
which occurs in connection with hemicrania, which, though 
sometimes apparently of gastric origin, is nevertheless pre- 
dominately and essentially nervous. The vertigo is generally 
slight in degree, though it may be severe. It usually mani- 
fests itself by dizziness, or a sensation of confusion in the head, 
of objects apparently moving or revolving, and of a tendenc} T , 
it may be, to fall. It is not often that the patient actually 
reels, but he feels insecure upon his feet, and if standing upon 
an elevated position, experiences a dread of falling. It is 
caused, as well as intensified, by emotional excitement, by the 
presence of a large company, or the reception of disagreeable 
news. It bears some resemblance to the " aura" of epilepsy 
and some other nervous affections, and the resemblance is 
heightened by the gastric disturbance, flatulency, and palpita- 
tion of the heart, which sometimes accompany it. Hence the 
subjects of it are apt to imagine that they are in danger of 



276 INTRACRANIAL DISEASES. 

falling victims to some serious intracranial disorder. But the 
fact that there is neither deafness nor loss of consciousness, is 
sufficient to distinguish it from both auditory vertigo and 
epilepsy. When associated with hemicrania, its intimate re- 
lation to the other symptoms of that complaint is amply suffi- 
cient to identify it. 

5. Intracranial Vertigo. — Vertigo is sometimes associated with 
epilepsy, apoplexy, cerebral tumors, and other forms of intra- 
cranial disease. It is an invariable symptom of ataxy, whether 
of cerebral or of spinal origin; and its connection with epi- 
lepsy, and other cortical diseases of the brain, renders it highly 
probable that it may be due in some cases to cortical lesions. 
It may coexist with epilepsy, or it may take the place of the 
epileptic fit. It is sometimes difficult to distinguish this form 
of vertigo from that of Meniere's disease, but the latter is more 
apt to be followed by vomiting, and besides, is not usually 
accompanied by loss of consciousness. 

Treatment. — General Indications. — Labyrinthine or Auditory 
Vertigo. — Aeon., China, Chin, sulph., Cicuta, Con., Colch., 
Kalmia, Natrum salicyl., Rosa damas., Salic, ac. 

Ocular Vertigo. — Arm, Argent, nit., Caust, Cuprum acet., 
Euphras., Gels., Kali iod., Merc, Nux vom., Opium, Paris 
quad., Phos., Physost. ven., Rhus tox., Senega, Spig. 

Gastric Vertigo. — Apomorph., Ars., Bry., Calc, Carbo veg., 
China, Ipec, Igna., Natr. mur., Xux vom., Phos., Puis., Sep., 
Sulph., Tarant., Verat. 

Nervous Vertigo. — Ars., China, Chin, sulph., Fer., Igna., Nux 
vom., Phos., Phos. ac, Puis., Silic, Zinc 

Epileptic Vertigo. — Ars., Amyl. nit., Bell., Calc. carb., Cocc, 
Glonoin, Hyosc, Laches., Stram., Tarant. 

Special Indications. — Aconite. — Auditory vertigo, w r ith reeling ; 
worse when bending forward or going down stairs ; vertigo on 
raising the head, or on rising from a recumbent position; 
vertigo with sensation of intoxication, the patient staggering 
like a drunken man ; great fear of falling ; nausea. 

Amyl nitrite. — Auditory vertigo, with a bursting sensation 



VERTIGO. 177 

in the ears, as if the drum of each ear would be forced out 
with each beat of the heart ; great throbbing in the ears and 
head, with confusion ; vertigo, with sensation as if a vapor 
spread from her, through her head, and renders her powerless; 
slight nausea, with uncomfortable feeling of the stomach ; 
precordial anxiety; she turned deadly pale, felt very giddy, 
then became partially unconscious, remaining so for ten 
minutes ; mental confusion and a dream-like state. 

Apomorphia. — Labyrinthine or gastric vertigo, attended with 
giddiness, singing in the ears and slight deafness ; nausea, 
with vomiting and retching ; nausea coming on at intervals ; 
sudden vomiting, almost without nausea; syncope, with lessen- 
ing of blood pressure. 

Argentum nit. — Ocular vertigo caused by weakness or pa- 
ralysis of the ciliary muscle ; transitory blindness, nausea, and 
confusion of the senses ; sensation of expansion when looking 
high up in the street ; trembling weakness when walking with 
shut eyes, or when walking in streets with high houses, as 
though they would fall upon him. 

Arsenicum. — Gastric, nervous, or epileptic vertigo, with reel- 
ing, as if intoxicated ; vertigo as if one would fall, especially 
when closing the eyes ; nausea and disposition to vomit in a 
recumbent position, less when sitting up; burning in the 
stomach, with vomiting ; vertigo coming on periodically, with 
coldness, followed by fever, loss of appetite, and vomiting. 

Belladonna. — Epileptic vertigo, caused by rush of blood to 
the head, with heat and redness of the face, buzzing in the 
ears, dimness of vision, and loss of consciousness; vertigo 
accompanied by luminous vibrations before the eyes, espe- 
cially when stooping or bending the head : vertigo, with 
vanishing of sight, and a tendency to fall backward or to the 
left side ; aggravated in a warm room ; ameliorated in the 
open air. 

Bryonia. — Gastric vertigo, with nausea and disposition to 
faint ; weakness and distention of the stomach, flatulence, and 
constipation ; burning in the stomach and vomiting ; aggra- 
vated by rising from a recumbent position and by motion ; 
ameliorated by rest and by lying down. 



278 INTRACRANIAL DISEASES. 

Calcarea carb. — Gastric or epileptic vertigo ; distention of the 
stomach and bowels, flatulence, and constipation ; stupefaction 
of the head, with vertigo ; sensation of coldness in the brain ; 
vertigo with roaring in the ears and nausea, especially when 
stooping or rising up suddenly ; vertigo caused by congestion 
of blood to the head. 

Causticum. — Ocular vertigo caused by paralysis of any of the 
ocular muscles ; congestion of blood to the head, with heat ; 
vertigo brought on by taking cold ; sudden and frequent loss 
of sight, with a sensation of a film before the eyes ; inclination 
on stooping to fall backward, on looking up to fall towards the 
left side. 

China. — Auditory, gastric, or nervous vertigo, especially 
when caused by debility from loss of animal fluids; vertigo, 
nausea, and fainting, with pale face and ringing in the ears, 
from anaemia ; vertigo, with nervous weakness and debility ; 
vertigo, with an empty stomach. 

Chininuw sulph. — Auditory vertigo, with hammering and 
humming in the ears, and partial deafness; vertigo, with head- 
ache, cerebral congestion, and deafness; vertigo occurring pe- 
riodically, with chills and fever, especially when of malarious 
origin. 

Cicuta. — Auditory vertigo, associated with aural disease, dis- 
charge of blood from the ears, loud sounds when swallowing, 
and hardness of hearing ; tinnitus aurium, worse in the room 
than in the open air. 

Cocculas. — Epileptic vertigo, with reeling, nausea, loss of 
consciousness, and sudden falling to the ground ; vertigo ag- 
gravated by motion, noise, smoking, coffee, sitting up in bed, 
and riding in a carriage. 

Colchicum. — Auditory vertigo, with chronic discharge from 
the ears, and hardness of hearing ; vertigo, with roaring and 
stoppage of the ears ; ameliorated by rest. 

Conium. — Ocular or auditory vertigo, with sensation as if 
turning in a circle ; vertigo caused by looking steadily at an 
object; vertigo on rising up or going down stairs; also when 
lying down or turning over in bed ; great debility and incli- 
nation to sleep. 



VERTIGO. 279 

Cuprum. — Ocular vertigo caused by paralysis of the nervus 
abducentis ; vertigo when looking up, with loss of sight, as if 
gauze were before the eyes ; vertigo, with sensation of turning 
round, or revolving vertigo ; vertigo from cerebral conges- 
tion ; vertigo with extreme weakness, especially of the lower 
extremities. 

Euphrasia. — Ocular vertigo from paralysis of the ocular 
muscles, especially when caused by taking cold, or when asso- 
ciated with coryza ; blurring of the eyes, relieved by winking. 

Gelsemium. — Ocular or nervous vertigo ; vertigo from para- 
lysis of the ocular muscles ; vertigo with reeling and stagger- 
ing, even unto falling ; heaviness of the head, with imperfec- 
tion of sight and dulness of mind ; aggravated by smoking. 

Hyoscyamus. — Epileptic or ocular vertigo, with reeling, loss 
of sight, hearing, and consciousness; diplopia, or double vision; 
red, sparkling, staring, and distorted eyes. 

Ipecacuanha. — Gastric vertigo, with nausea and vomiting; 
abdominal distention, with flatulency, colic, and diarrhoea; ver- 
tigo, with loss of appetite, empty retching, and qualmishness. 

Ignatia. — Gastric, nervous, or epileptic vertigo ; vertigo fol- 
lowed by nausea, and vomiting of slimy, sourish fluid ; burn- 
ing in the stomach ; abdominal distention, with flatulency, 
and constipation ; restless, changeable disposition ; vertigo 
caused by mental emotion; worse from stooping or moving 
the head. 

Kali iod. — Ocular vertigo in syphilitic individuals; dimness 
of vision, with twitching of the eyeballs ; burning in the eyes, 
with sensation of a film before the sight, relieved by winking. 

Kalmia. — Auditory vertigo, with sensation when turning as 
of something loose in the head; vertigo while stooping or 
looking downward ; palpitation of the heart. 

Lachesis. — Epileptic vertigo, with reeling, foiling, and loss of 
consciousness; frequent momentary vertigo, particularly on 
closing the eyes, sometimes with paleness, nausea, and vomit- 
ing ; vertigo with headache, congestion of blood to the head, 
and cold extremities. 

JSfatrum mur. — Gastric vertigo, with reeling, and obscuration 
of sight; sensation of everything turning in a circle when 



280 INTRACRANIAL DISEASES. 

walking: nausea and sudden sinking of strength; burning 
and feeling of pressure in the stomach : want of appetite and 
aversion to food; vertigo, with nausea and heartburn after 
eating. 

Natrwm salicyl. — Labyrinthine vertigo, with tendency to fall 
to the affected side, whilst surrounding objects appear to move 
in the opposite direction : noises in the affected ear, with de- 
fective hearing : vertigo, with inclination to fall towards the 
left side. 

V . ■;■. i. — Ocular, gastric, or nervous vertigo: vertigo from 
paresis of the ocular muscles, especially when aggravated by 
stimulants or tobacco : vertigo,, with tendency to faint, wc 
during and after meals: vertigo associated with dyspepsia and 
constipation : vertigo brought on by mental exertion, seden- 
tery habits, high living, or haemorrhoids: vertigo in hysterical 
and nervous subjects. 

um. — Ocular vertigo depending on paralysis of the ac- 
commodation : vertigo with stupefaction of the senses, or ai 
fright : apoplectic symptoms with vertigo : pale or bloated 
face, with dimness of sight, and tendency to faint: amelio- 
rated by rest. 

Phosphorus. — Ocular, gastric, or nervous vertigo, especially 
when caused by nervous debility, sexual abuse, spermator- 
rhoea, haemorrhoids, etc. : vertigo accompanied by reeling, 
nausea, and vomiting: vertigo occurring in the morning, 
with an empty stomach, after eating or sleeping, during or 
after the menses, or with fainting and trembling. 

Phosphoric acid. — Xervous vertigo, especially when caused 
by cerebral or nervous exhaustion : vertigo, with great dispo- 
sition to sweat during the day: night-sweats, with vertigo; 
vertigo from onanism, loss of animal fluids, or mental exer- 
tion, anxiety, or overwork. 

Physostigma. — Ocular vertigo from partial or complete 
ralysis of the ciliary muscle ; has been applied with benefit as 
a local application. 

P IsaiULa. — Gastric or nervous vertigo, with reeling, espe- 
cially in the evening, when walking, when lying down, or 
before the menses : vertigo followed bv vomiting or a ten- 



VERTIGO. 281 

dency thereto; worse stooping, or rising up quickly from a 
recumbent position. 

Senega. — Ocular vertigo, especially when caused by paresis 
or paralysis of the superior rectus or superior oblique muscle 
of the eye, or when the vertigo and double vision are relieved 
by bending the head backward. 

Sepia. — Gastric or nervous vertigo, especially when caused 
by a dyspeptic condition ; vertigo, with flatulency and consti- 
pation; worse when drinking, while looking upwards, or while 
looking from a great height, a large assemblage of people, or 
an extended plain. 

Silicea. — Nervous or ocular vertigo, especially when brought 
on by severe physical or mental labor, reading, writing, or sew- 
ing; vertigo accompanied by nausea, and aggravated by mo- 
tion or by looking upwards; vertigo during sleep, or when ris- 
ing from a recumbent position. 

Spigelia. — Ocular or epileptic vertigo, especially when as- 
sociated with sharp, stabbing pains through the eyes and 
head; vertigo, with reeling or staggering, followed by loss of 
consciousness. 

Stramonium. — Epileptic vertigo, especially when walking in 
the dark, day or night ; vertigo followed by stupefaction of 
all the senses and complete insensibility; vertigo accompanied 
by strange fancies. 

Sulphur. — Gastric vertigo, especially in the morning after 
breakfast, with nausea; dimness of vision, with inclination 
to fall to the left ; chronic vertigo, especially if preceded by a 
suppressed eruption. 

Tarantula. — Gastric, nervous, or epileptic vertigo, so severe 
as to cause him to fall, but without losing consciousness ; 
nausea, bloating of the stomach, and disposition to vomit; 
vertigo after breakfast, with a bad taste in the mouth ; vertigo 
from fixing the sight on any object. 

Veratrum. — Gastric vertigo, with cold perspiration on the 
forehead ; vertigo, with sensation as if everything in the head 
was loose ; loss of appetite, with burning stomach, distended 
abdomen, flatulency, vomiting, and diarrhoea. 



282 INTRACRANIAL DISEASES. 



CHAPTER III. 

INSOMNIA. 

Sleep may be defined to be, a normal suspension of the 
functions of the cerebral hemispheres. True sleep is just as 
much a normal condition of the organ of the mind as its 
opposite, the state of true consciousness, or voluntary mental 
activity. These two conditions alternate with each other at 
regular periods during a state of health, and cannot be greatly 
disturbed without causing disease. If the former state is 
prolonged much beyond its natural duration, it constitutes 
sopor or stupor; if the latter, wakefulness or insomnia. 

Insomnia may be either partial or complete. Partial in- 
somnia is when the patient is able to obtain only a portion of 
his usual allowance of sleep. He either lies awake one or 
more hours before he can get to sleep, or he awakes some 
hours earlier than is his natural habit, so that he obtains con- 
siderably less than the normal quantity of sleep. In this 
respect, however, every individual is a law unto himself. The 
amount of sleep that is normal for one person may be abnormal 
for another, and vice versa. On the other hand, the patient 
may not be able to obtain any sleep wmatever, for several suc- 
cessive nights, as in acute mania, violent fevers, or when suf- 
fering from severe pain, profound grief, or great mental 
disturbances. This constitutes complete insomnia, and always 
indicates a dangerous degree of mental activity. 

Disturbed or restless sleep is a defect in quality, rather than 
in quantity, of sleep, though the two conditions frequently 
coexist. This state, as well as that of insomnia, may be 
caused by fatigue of the body or mind ; by anxiety or mental 
excitement ; by indigestible food, food taken in undue quan- 



INSOMNIA. 283 

tity, or at unreasonable hours; uncomfortable conditions of the 
body induced by exposure to cold, heat, etc.; loud or continu- 
ous noises; pain of any kind; and anaemia and hyperemia 
of the brain, both of which conditions of the cerebral circu- 
lation are obnoxious to healthy and quiet sleep. It is true 
there is a less active circulation in the brain during healthy 
sleep than during the waking periods, but this is not the 
condition known as cerebral anaemia, w T here the blood is either 
deficient in quality or quantity, and which is as unfriendly to 
sleep as is the opposite state of hyperemia. 

Treatment. — The removal or avoidance of the cause is a 
matter of the highest importance in the treatment of insomnia ; 
one, the neglect of which will, in the majority of cases, result 
in failure, notwithstanding the greatest care in the selection of 
indicated remedies. Moreover, sleeplessness is generally a 
symptom of some other disease, the removal or relief of which 
is necessary for the cure of the secondary affection. Hence, we 
do not deem it necessary to give many remedies or sympto- 
matic indications for this disorder, which is often best treated 
on physiological principles. 

General Indications. — Sleeplessness before Midnight: Ars., Bell., 
Bry., Cale carb., Carbo an., Carbo veg., Chin., Con., Cycl., Graph., 
Ign., Kali carb., Laches., Lye, Merc, Natr., Nitric ac, Phos , 
Puis., Khus tox., Selen., Sep., Sil., Spig., Staph., Sulph., Valer. 

Sleeplessness after Midnight: Ars., Asafcet , Aur., Caps., CofT., 
Hep., Hyosc, Kali carb., Laches., Lye, Mere, Natrum, Nitric 
ae, Nux vom., Plat., Puis., Rhodod., Rhus tox., Samb., Sep., 
Sil., Sulph. ae, Thuja. 

Waking too early: Ars., Asafcet., Bry., Cale carb., Coff., Croc, 
Dule, Hep., Ign., Kali carb., Lye, Magn., Mur. ae, Natr. carb., 
Nux vom., Phos. ae, Ran. bulb., Rhod., Sep., Sil. 

Waking frequently : Ant. crud., Arm, Ars., Bell., Bism., Cale 
carb., Cann., Carbo. an., Caust., Cham., Chin., Cie, Coff., Digit., 
Fluor, ae, Graph., Hep., Kali carb , Lye, Mang., Mere, Nitric 
ae, Nux vom., Phell., Phos., Puis., Rhus tox., Ruta, Samb., 
Selen., Sep., Sil., Staph., Sulph., Sulph. ae, Tereb., Teue, Zinc. 

Retarded Sleep : Alum., Anae, Ant. tart., Ars., Bell., Bry., 



284 INTRACRANIAL DISEASES. 

CalacL, Carbo an., Carbo veg., Caust., Chin., Creos., Gels., Graph., 
Guaj., Ign., Lach., Led., Lye, Merc., Natr. carb., Xatr. mur., 
Nux vom., Petr., Phos., Puis., Rhus tox., Selen., Sep., Sil., Spig., 
Stann., Sulpli. 

Special Indications. — Aconite. Sleeplessness from anxiety ; 
sleeplessness of infants and aged people ; sleeplessness in con- 
sequence of febrile symptoms ; great restlessness and tossing 
about. 

Belladonna. — Insomnia with drowsiness ; congestion of blood 
to the head. 

Cocculus. — Sleepless from mental activity or from night- 
watching ; sleep retarded, restless, and frequently interrupted 
by wakings and startings. 

Coffea. — Sleeplessness of infants; sleepless from joy, long 
watching, overexcitement of mind. 

Gelseminum. — Drowsy and sleepless, or else wide-awake and 
unable to get to sleep ; insomnia from Cerebral irritation and 
congestion. 

Hyoscyamus. — Sleepless from nervous excitement; wild, star- 
ing eyes ; tendency to delirum. 

Ignatia. — Sleepless from grief or depressing emotions ; sleep- 
lessness from nervous exhaustion. 

Moschus. — Nervous excitement preventing sleep ; is awakened 
by sense of heat, rendering the covering uncomfortable ; re- 
lieved by throwing off the covering. 

Nux vom. — Sleepless from overwork, mental or bodily ; too 
close study at night ; abuse of narcotic stimulants. 

Opium. — Great wakefulness or drowsiness, with inability to 
get to sleep; insomnia with acuteness of hearing, the ticking 
and striking of the clock, cock crowing, and other noises, keep- 
ing the patient awake. 

Phosphorus. — Gets to sleep too late ; insomnia from nervous 
debility, especially when brought on by onanism or sexual 
abuse. 

Pulsatilla. — Sleeplessness after late suppers, or from indiges- 
tion ; determination of blood, especially to the head and sur- 
face of the body, rendering the patient extremely restless, sleep- 
less, and uncomfortable. 



INSOMNIA. 285 

Stramonium. — Sleepless from nervous excitement; sleep in- 
terrupted by frightful screams ; restless sleep full of dreams ; 
tendency to delirium. 

Sulphur. — Sleepless from nervous excitement, cutaneous irri- 
tation, and external heat. 

Veratrum vir. — Sleeplessness from determination of blood to 
the brain, or from a general febrile condition. 

Zinc, valer. — Sleeplessness with pains in the head, especially 
in children ; frequent waking in the night ; drowsy, with pale 
and tired expression of the countenance. 



286 INTRACRANIAL DISEASES. 



CHAPTER IV. 

COMA. 

Coma is often regarded as a profound state of sleep, or the 
opposite of insomnia, and in one sense this definition is true ; 
for as insomnia is a state of extreme wakefulnes (pervigilium), 
so coma, a term derived from a Greek word signifying " deep 
sleep," is a state of profound insensibility, somewhat allied to 
sleep, but in which the loss of consciousness is more complete 
and absolute than in any form of true sleep. Hence the terms 
sopor, lethargy, and stupor are employed to designate the lesser 
degrees of insensibility, from that of sleep, properly so called, 
up to that of profound anaesthesia, in wdiich there is complete 
loss of consciousness, that is to say, true coma. And as there 
are different degrees of stupor, so there are different degrees 
of coma, namely, what is known as the comatose state, coma, 
and profound coma, the last of which was called by the older 
writers cams, the gravest of the graver states of unconscious- 
ness and insensibility. In this condition the breathing is very 
slow and stertorous, accompanied by puffing of the cheeks ; 
the pulse, which at first is strong and regular, becomes feeble 
and irregular ; there is often lividity; and the pupils, which 
are generally excessively dilated, are immovable and totally 
insensible to light. But in the lighter forms of coma there is 
usually more or less delirium; the patient mutters slightly, 
and grasps feebly, but unconsciously and without purpose, at 
any object in his way. This is the form of coma met with in 
many low fevers, whilst the former is the coma of apoplexy. 

Diagnosis. — The symptoms of coma above given are suffi- 
ciently characteristic, in most cases, to distinguish this affection 
from every other. It is important, however, to remember that 



coma. 287 

even complete insensibility is not always coma. Thus, in 
syncope we have insensibility or unconsciousness resulting from 
a cutting off of a due supply of blood to the brain ; whilst in 
asphyxia we have a similar result from an interference with 
the function of respiration. Again, we may have a condition 
of profound narcosis, resulting from the poisonous effects upon 
the brain of opium, alcohol, and other drugs, or of certain 
urinary products which the kidneys have failed to eliminate 
(ursemia). In all these cases we have, in addition to the coma- 
tose state, certain characteristic symptoms belonging to each 
affection, the presence of which will always serve to distinguish 
the condition from that of simple coma. Thus, in syncope 
there is fainting ; in asphyxia, deficient respiration ; in nar- 
cosis, the peculiar effects of the agent or drug producing it ; 
and in uraemia, convulsive movements, vomiting, etc. 

Causes. — The most common cause of coma is cerebral 
haemorrhage (apoplexy). Coma may also result from sunstroke, 
long exposure to severe cold, typhoid and other low fevers, 
epilepsy, erysipelas of the head and face, inflammation of the 
cerebral meninges, and various organic diseases of the brain 
and its membranes, such as tumors, multiple embolisms, etc. 

Prognosis. — Coma, in whatever way it may be produced, is 
always an extremely dangerous condition ; for if the patient 
cannot be roused at all within one or two days at farthest, or 
if the coma does not gradually diminish in intensity by pass- 
ing into the state of simple stupor, it will probably soon ter- 
minate in death. 

Treatment. — One of the most important matters relating to 
the treatment of coma is that of food or nourishment. Nothing 
should be allowed to the patient, in the way of aliment, except 
water and the juice of oranges and grapes. Anything more 
than this is certain to do harm. It is folly to suppose that 
coma can be relieved by medicine, or in any other way, while 
the blood-vessels are kept in a state of repletion by the ingestion 
of any form of nutriment. I should not deem it necessary to 
mention so obvious a matter, were it not that I have more 
than once seen the lives of patients placed in the greatest 
jeopardy by this senseless course on the part of nurses, and, I 
am sorry to say, of intelligent physicians also. 



288 INTRACRANIAL DISEASES. 

Special Indications. — Belladonna. — Stupor with snoring, dark 
red face, swelling of the cheeks, and congestion of blood to the 
head ; deep sleep, attended by screaming, singing, muttering, 
or frequent startings; eyes half open, but insensible to light. 

Bryonia. — Great drowsiness or heavy stupor, with or without 
delirium; moanings and startings in sleep, with fever, and 
sometimes with loud cries. 

Camphora. — Sopor and delirium, with chilliness and coldness 
of the body; talking and snoring in the sleep; congestion of 
blood to the head; face red, but sometimes pale. 

Chamomilla. — Soporose condition, with feverish restlessness, 
especially in children; snoring and starting in the sleep; de- 
lirium, with moaning, talking, or screaming; comatose condi- 
tion of children during dentition, especially when caused by 
diarrhoea. 

Helleborus. — Sopor, especially when resulting from an attack 
of acute or chronic hydrocephalus; fever, with hot head and 
cold hands and feet; urine scanty or suppressed. 

Lachesis. — Comatose symptoms, especially when resulting 
from erysipelas of the head and face; constant sopor after the 
cessation of the pains; tossing about, particularly in children, 
with moaning. 

Phosphoric acid. — Sopor, especially in the daytime; being 
roused, he answers correctly, but immediately falls asleep 
again ; typhoid fever, particularly when accompanied by pro- 
fuse sweating. 

Pulsatilla. — Deep sleep, wuth snoring inspirations; valuable 
in cases complicated with erysipelas. 

Rhus tox. — Especially valuable in the coma of typhoid fever 
and erysipelas; sopor, with snoring, muttering, and grasping 
at flocks. 

Nux moschata. — Sopor, with or without delirium; valuable 
in low forms of fever, especially wdien accompanied by putrid 
or colliquative diarrhoea; also in children during the diarrhoea 
of teething. 

Opium. — Profound coma, such as occurs in apoplexy, with 
stertorous breathing, dilated pupils, dark red and bloated face, 
and feeble, irregular pulse; mouth open, eyes half closed, and 
insensible to light. 



coma. 289 

Secede cor. — Long-continued stupor, with, delirium and start- 
ings; cold, viscid sweat; face red or pale; foetid and colliqua- 
tive diarrhoea ; suppression of urine. 

Stramonium. — Deep sleep, with stertorous respiration, and a 
bloody froth at the mouth ; epileptic coma. 

Tartar emet. — Coma with constant yawning and stretching, 
especially when arising from irritation or congestion of the 
brain ; great prostration, with trembling of the limbs ; coma of 
delirium tremens. 

Veratrum alb. — Protracted stupor, especially when accompa- 
nying the collapse of diarrhoea or cholera; coldness of the 
whole body. 



19 



290 INTRACRANIAL DISEASES: 



CHAPTER V. 

SUNSTROKE. 

Syn. : Coup de Soleil ; Insolatio ; Thermic Fever. 

Sunstroke and thermic fever are certain forms of cerebral 
exhaustion resulting from prolonged exposure to solar or arti- 
ficial heat. They are accompanied by one or another of the 
three primary forms of insensibility and unconsciousness, 
namely, syncope, asphyxia, or coma. 

Varieties. — The differences above noted give rise to three 
well-marked varieties of insolation, namely : 1. The syncopal 
form, from exhaustion and failure of the heart's action ; 2. 
The asphyxial form, from shock communicated chiefly to the 
respiratory centre, and interfering with the action of the lungs ; 
and 3. The hyperpyrexial form, from shock communicated 
chiefly to the heat centre, causing vaso-motor paralysis and 
intense fever. 

1. The Syncopal Form. — This form of sunstroke, sometimes 
called " heat-exhaustion," is the kind of nervous depression re- 
sulting from exposure to a high temperature, and # causing syn- 
cope. The muscular and nervous systems are completely 
prostrated ; the skin is moist, pale, and cold ; the pulse, feeble 
and quick. This form of the disease is most apt to occur in 
fatigued, overworked, and delicate persons, especially those 
who faint easily, or who have previously suffered from sun- 
stroke. The nervous exhaustion may be so great that the 
S3 7 stem can never rally from the collapse produced by the 
failure of the heart's action, but on the other hand complete 
recovery is more common in this form than in either of the 
others. 

2. The Asphyxial Form. — This is the form to which the term 



SUNSTROKE. 291 

sunstroke is commonly applied. The symptoms are those of 
extreme depression following exposure of the head and spine 
to the direct rays of the sun, at a time when the body is 
greatly fatigued and overheated, and the atmospheric tempera- 
ture is very high. The attack may or may not be preceded 
by premonitory symptoms, such as extreme thirst, giddiness, 
faintness, frequent disposition to urinate, stupidity, and drowsi- 
ness. Unless relieved, the patient either gradually or sud- 
denly, but generally suddenly, sinks into a state of uncon- 
sciousness and insensibility, with cold skin, feeble pulse, ster- 
torous breathing, and a more or less rapid failure of the 
respiration and circulation. Death may take place speedily, 
or reaction may set in, and life be preserved, but at the ex- 
pense, in many cases, of various injuries to the cerebro-spinal 
system, such as chronic headache, weakness of memory, great 
nervous prostration and irritability, partial or complete blind- 
ness, paralysis, meningitis, insanity, or dementia. But the 
most common sequla of the disease is an extreme intolerance 
of the sun's heat, or indeed any form of heat, and this intoler- 
ance may endure for years, and even for life. 

3. The Hyperpyrexial Form. — This form of insolation, some- 
times called "heat-fever" or "thermic fever," is an intense 
fever resulting from the influence of heat upon the nerve- 
centres, thereby causing vaso-motor paralysis, and Consequent 
overheating of the body generally. Although the attack is 
caused, primarily, by exposure to undue heat, either solar or 
artificial, it does not necessarily depend upon the immediate 
action of the sun's rays, as it frequently occurs at night, or in 
the shade. The nerve-centres generally, but especially the 
respiratory centre, are overstimulated by the heat, and this is 
soon followed by exhaustion. The vaso-motor paralysis thus 
induced causes the temperature of the body to rise to 108°, 
109°, and, in some cases, to 110° F., and even higher. This 
gives rise to intense fever, extreme thirst, and frequent mictu- 
rition ; there is a burning skin, which may be either dry or 
moist; dyspnoea, with quick, gasping, and irregular respira- 
tion, and great restlessness ; a strong determination of blood 
to the head, attended by visible pulsations of the carotids, and 



292 INTRACRANIAL DISEASES. 

dark, livid appearance of the face and neck. The pupils, 
which are at first contracted, sometimes become widely dilated. 
The pulse also varies, being in some cases rapid and jerking, 
in others, full, slow, and labored. Unless relief is soon 
obtained, convulsions, delirium, paralysis, with relaxation of 
the sphincters and suppression of urine, set in, followed by 
death from asphyxia and coma. 

Like the other forms of sunstroke, this variety of insolation 
is often attended by premonitor} T symptoms, such as headache, 
giddiness, thirst, loss of appetite, nausea, vomiting, frequent 
micturition, hurried respiration, precordial anxiety, and a 
general feverish state of the system, but differs from the first 
two forms in the length of time that the prodromata may 
manifest themselves before the attack culminates, which is 
often several hours, and in some cases clays. 

Morbid Anatomy. — In rapidly fatal cases of sunstroke, 
neither the brain, lungs, nor heart are apt to exhibit any 
very marked morbid appearances after death. The brain and 
its membranes are sometimes slightly congested, and the 
same may be said of the lungs. The greatest changes, how- 
ever, are observed in the venous trunks, especially those of the 
abdomen, the right side of the heart, and the pulmonary 
vessels, all of which are sometimes overloaded with dark, 
grumous blood ; patches of ecchymoses are also scattered over 
the surface of the body, rendering it more or less livid. These 
appearances are chiefly the effect of nervous shock, which, by 
paralyzing the heart and lungs, leaves the venous system in 
an engorged condition. 

In thermic cases a similar condition often exists, but usually 
in a more pronounced form, together with a more or less 
congested state of the brain and its membranes. Cerebral 
haemorrhage and serious ventricular effusions may also exist, 
but the real cause of death in these cases is asphyxia, and not 
apoplexy, as was once thought. This is forcibly illustrated 
by the post-mortem appearances in the three fatal cases ob- 
served by surgeon Eussel at Madras. " The brain," he says, 
"was, in all, healthy; no congestion or accumulation of blood 
was observable ; a very small quantity of serum was effused 



SUNSTROKE. 293 

under the base of one, but in all three the lungs were con- 
gested even to blackness through their whole extent ; and so 
densely loaded were they, that complete obstruction must have 
taken place. There was also an accumulation in the right 
side of the heart, and the great vessels approaching it." * 

Causes. — A hot, close and moist atmosphere, overexercise, 
tight and unseasonable clothing, the breathing of vitiated air, 
and whatever tends to produce suffocation, all conspire to 
produce an attack; especially if there be superadded, great 
bodily fatigue, a heated atmosphere, or prolonged exposure to 
the direct rays of the sun. Hence soldiers, especially those 
serving in hot climates, often suffer from sunstroke, their 
warm, tight-fitting uniforms, heavy accoutrements, and long, 
weary marches, predisposing to, and frequently precipitating, 
such attacks. Certain classes of out-door laborers are also 
liable to become sun struck in very hot weather, especially 
harvest hands, common laborers upon our railroads and in 
our large cities, very few of whom take the precaution to 
properly guard themselves against the effects of the sun's rays. 

Prognosis. — Statistics show that sunstroke proves fatal to 
nearly one-half of those attacked ; but even of those who re- 
cover a large proportion are permanently injured by it, whilst 
some of them, as we have seen, are rendered complete wrecks, 
both in body and mind. 

Treatment. — The syncopal form of sunstroke generally 
requires but little active treatment, further than removing the 
patient to a cool and shady place, loosening the clothing, and 
administering by inhalation a few drops of Amyl nitrite. But 
in ordinary cases of sunstroke, where the patient has long 
been exposed to the direct rays of the sun, or where the tem- 
perature of the body is greatly elevated above the normal 
standard, the burning temperature of the surface should be 
reduced as quickly as possible by the free application of the 
cold water douche, ice and ice-water to the head and neck, 
cool air, fanning, etc, at the same time endeavoring to over- 
come the great nervous depression and consequent embarrass- 

* Graves' Clinical Medicine, 3d Am. ed., p. 118. 



294 INTRACRANIAL DISEASES. 

ment of the circulation, by the cautious administration of 
stimulants, especially Camphor, which is homoeopathically 
indicated. Whenever practicable, the cold effusion to the 
head, neck, and shoulders, continued until the temperature 
sinks to 98° or 100° F., is the most speedy and effective way 
of rescuing the patient from the impending danger. At the 
same time, care should be taken not to continue cold applica- 
tions too long, as danger may result from reducing the tem- 
perature below the normal standard. 

After the patient has recovered from the immediate effects 
of the stroke, the nervous depression and other sequels of the 
disease will be best met by time, which is always an essential 
element of cure in these cases, aided by proper medication. 
These after-results, as before stated, are often extremely per- 
sistent, and give rise to great physical prostration, which often 
lasts for years — a condition which, aside from mere medical 
treatment, calls for the exercise of sound discrimination and 
judgement as to clothing, climate, and other hygienic influ- 
ences. The clothing in particular should be carefully adapted 
to the season and the sensibility of the patient, being neither 
too thick and warm, nor too thin, since both heat and cold 
are oppressive and injurious. For this reason, whenever 
practicable, the patient should go north in summer and south 
in winter, and this should be repeated, if necessary, from year 
to year, until such time as the patient can safely bear the 
varying temperature of his own home. Where a change of 
climate cannot be had, underclothing made of soft buckskin, 
fur, or other warm material, may be worn in winter, and such 
other precautions taken to guard against the injurious effects 
of cold and heat, as the peculiar circumstances of the patient 
may render necessary. Finally, in those cases where nervous 
exhaustion is the chief difficulty to be overcome, the patient 
should be encouraged by the assurance that time, which, as 
already stated, is an essential element of cure, will, in con- 
junction with suitable remedial measures, finally restore him 
to perfect health. 

General Indications. — Premonitory Symptoms. — Aeon., Ant. 
crud., Ars., Bry. ; Carbo veg., Gels., Laches., Verat. vir. 



SUNSTROKE. 295 

During the Attack. — Amyl nit., Bell., Camph., Glonoin, Opium, 
Verat. alb. 

For the Sequelae. — Agar., Anac, Ars., Baryta carb., Bell., Gels., 
Glon., Laches., Nat., Stram. 

Special Indications. — Aconite. — Thermic form, accompanied by 
burning heat, especially in the head and face, dryness of the 
skin, redness of the eyes and cheeks, thirst, headache, restless- 
ness, anxiety, nausea, vomiting. 

Amyl nit. — Violent determination of blood to the head and 
face; head feels as though it would burst; violent beating of 
the carotids ; vertigo, with sense of intoxication ; anxiety ; 
dyspnoea ; prostration. 

Antimonium crud. — Syncopal form, with fainting, loss of ap- 
petite, furred tongue, nausea, vomiting; aggravated by ex- 
posure to the sun. 

Antimonium tart. — Thermic fever, with much gastric dis- 
turbance, great prostration, tendency to fainting, convulsions, 
paralysis. 

Arsenicum. — Excessive thirst, burning skin, fainting, nausea 
and vomiting, great prostration, diarrhoea. 

Belladonna. — Indicated when the brain symptoms pre- 
dominate, such as headache, giddiness, delirium, sensitiveness 
to light and sound, great anguish, etc.; also apoplectic symp- 
toms, such as coma, stertorous breathing, lividity, etc. 

Bryonia. — Tendency to syncope, thirst, gastric disturbances, 
weakness of the limbs, great uneasiness and apprehension. 

Cactus. — Violent determination of blood to the brain, with 
pulsations in the temples, bloodshot eyes, stupor, flushed face, 
epistaxis, cold sweat, fainting, oppression of the chest, great 
prostration. 

Carbo veg. — Extreme prostration of the vital power; vertigo, 
with heaviness of the head ; pulsative pains and pressure 
above the eyes; heat-exhaustion. 

Camphora. — Great depression of both the nervous and cir- 
culatory systems; oppression of breathing; coldness of the 
body ; tremors, cramps, and diarrhoea. 

Glonoin. — Intense headache, with throbbing in all parts of 



296 INTRACRANIAL DISEASES. 

the head and vertigo, especially when followed by loss of con- 
sciousness; painful constriction of the heart; sensation as if 
all the blood had gone to the head, which feels as though it 
would burst ; fainty feeling, with complete muscular relaxation ; 
convulsions; numbness in the limbs ; oppression of breathing; 
precordial anxiety. 

Veratrum vir. — Thermic fever, with congestion to the head 
and chest, gastric disturbances, coldness of the limbs ; faint- 
ness ; convulsions ; paralysis. 



CONCUSSION OF THE BRAIN. 297 



CHAPTER VI. 

CONCUSSION OF THE BEAIN. 

Concussion of the brain is usually regarded as a surgical 
disease, but it is so only when complicated with cerebral or 
other injuries. The symptoms are in the main the same, 
whether traumatic lesions exist or not ; and as the treatment 
is medical rather than surgical, we think it is fully entitled to 
a place among intracranial disorders. 

Cerebral concussion may be denned to be a shock communi- 
cated to the brain and nervous system by some external vio- 
lence, such as a fall or blow, whereby their functions are 
temporarily suspended, and the vital power more or less 
depressed. 

Symptoms. — The leading symptoms of concussion are: 
unconsciousness and insensibility, accompanied by a greater 
or less degree of pallor, coldness, and flaccidity of the volun- 
tary muscles. Sometimes the depression is very slight, and 
the patient quickly recovers ; at others, the shock is so severe 
as greatly to depress the system and retard recovery ; whilst 
at other times the depression continues and the patient sinks. 
In the more severe cases all power of motion is lost ; and if 
the patient is capable of being partially aroused, he immedi- 
ately relapses again into the former state of insensibility and 
unconsciousness. In this, the first stage of concussion, the 
pulse is slow and feeble, the pupils dilated or uneven, and the 
surface pale and cold. The second stage is characterized by 
the symptoms of reaction ; warmth and color gradually return, 
consciousness and the power of motion are restored, and the 
circulation is reestablished. This stage is usually accompanied 
by more or less vomiting, depending upon the severity of the 



298 INTRACRANIAL DISEASES. 

concussion. This vomiting is a favorable symptom, as it tends, 
by equalizing the circulation, to promote recovery. The third 
stage is marked by extreme physical prostration, a cold, 
clammy, semi-moribund condition, which sometimes continues 
for hours, and at last gradually yields to recover} 7 , or terminates 
in death. 

Morbid Anatomy. — As might be inferred, every degree of 
injury has been observed in fatal cases, and the instances are 
comparatively few in which no intracranial lesion is to be 
found. Sometimes actual rupture occurs ; at others, a soft or 
semi-diffluent state of the cerebral tissue is produced, whilst 
occasionally, even in those cases in which the shock and con- 
sequent depression are the greatest, no lesion whatever can 
be discovered. The visible lesions may be equally visible, 
from a contused, ecchymosed, or lacerated wound, with or 
without a broken skull, to a mere abrasion, or even a total 
absence of external injury. 

Pathology. — In those cases in which no lesion can be dis- 
covered after death, it is probable that the patient dies from 
the effect of shock alone; but of course this cannot be proven, 
because it cannot be shown that the cerebral tissue has entirely 
escaped injury. A minute haemorrhage or other injury at the 
internal origin of the pneumogastric nerve would be sufficient, 
no doubt, to produce speedy death, and the same may be true 
of other parts of the great nervous centre. Nevertheless, it is 
more reasonable to refer the fatal issue in these cases to shock 
alone, than to causes which may have no existence. In other 
cases, the injury to the brain interferes with the circulation 
through it, and though the effects of the concussion upon the 
general system may be no greater in these than in the former 
cases, the character of the injury is such as to permanently 
depress the vital power, and death sooner or later is the inevi- 
table consequence. 

Prognosis. — The prognosis differs greatly in different cases. 
As we have said, some cases quickly recover ; others rally 
slowly, the paralyzed brain gradually regaining its power and 
functions; and the patient, after remaining, it may be, for 
hours in a cold and semi-moribund condition, gradually re- 



CONCUSSION OF THE BEAIN. 299 

covering his activity and senses, but suffering for a longer or 
shorter period from headache, confusion of thought, giddiness, 
and impairment of the mental powers. In other cases, again, 
should the patient survive the immediate effects of the injury, 
an irritable state of the brain may remain, or such an impair- 
ment of its functions, as to render it liable to inflammation 
under the operation of almost any exciting cause, such as ex- 
cesses in eating and drinking, mental excitement, etc. On the 
other hand, if paralysis ensues, or if there is incontinence or 
retention of faeces and urine, it is highly probable that the 
case is complicated with cerebral laceration or contusion, and 
that the final result will be fatal. 

Treatment. — This should be similar to that recommended 
for the syncopal form of sunstroke (q. v.). Amy! nitrite by 
inhalation furnishes the speediest way of overcoming the 
depression of the vital powers, but care should be taken not to 
overstimulate the circulation by this or any other method, the 
aim being simply to reestablish the normal condition. In 
most cases it is not only safest, but sufficient, to wrap the 
patient in warm blankets, apply friction to the surface, and 
use dry heat to the extremities. In the case of young chil- 
dren, however, the warm bath may be employed with great 
advantage, care being taken to prevent their getting chilled 
during its administration. In the case of adults, on the con- 
trary, dry heat is the handiest mode of applying heat to the 
surface, the patient being surrounded by hot bottles, Chap- 
man's bags, or some other equivalent substitute. As soon as 
the patient is able to swallow, he may, if his friends so desire, 
be allowed to drink moderately of simple warm teas ; but alco- 
holic stimulants should be carefully avoided, as they are apt 
to have a highly prejudicial effect. So far as the concussion 
is concerned, the case is now one for medical treatment only, 
no other form of stimulation being required. 

General Indications. — First Stage. — Amyl nit., Arm, Ars., Cic, 
Coca, Camph.j Con., Lauroc, Verat. 

Second Stage. — Arm, Bry., Camph., Chin., Euphra., Hep., 
Hyos., Ign., Nux vom., Phos., Rhus tox., Sulph., Yerat. 



300 INTRACRANIAL DISEASES. 

Third Stage. — Cic, Cocc., Con., Dig., Ignat., Merc, Phos. ac. 
Rhus tox., Sulph. 

Muscular System. — Angus., Euphra., Phos. ac, Puis., Sulph. 
ac. : trembling — Angus., Cic, Cin., Hep., Ign , Nux vom. : con- 
vulsions — Am., Ars., Cocc, Con., Lauroc, Rhus tox., Sulph., 
Verat. : paralysis. 

Sensorium. — Dig., Euphra., Hep., Ign., Phos. ac, Ruta. Sulph., 
Verat. : giddiness — Angus., Cin., Con., Puis., Rhus tox., Sulph. 
ac : drowsiness — Am, Ars., Cic, Cocc, Laches., Lauroc, Merc, 
Opium : insensibility and unconsciousness. 

Special Indications. — Arnica. — Concussion from traumatic in- 
injury to the brain, attended with insensibility and uncon- 
sciousness : if fever ensues, alternate with Aconite. 

Belladonna. — Second stage, when accompanied by excessive 
reaction : delirium, convulsions, flushed face, intense head- 
ache : if high fever ensues, alternate with Aconite. 

Cicuta. — First stage of cerebral concussion, attended by 
insensibility and unconsciousness : lies in a state of complete 
insensibility, like a dead person ; face cold and deadly pale, 
with cold hands; inability to swallow: delirium; profound 
depression of the vital power ; convulsions. 

Gonium. — Apoplectic symptoms, with trembling of the limbs; 
want of animal heat: delirium: convulsions; paralysis; numb- 
ness ; slow, weak pulse ; dilatation of the pupils : collapse. 

Euphrasia. — Second stage, with great weakness of the whole 
body: soreness from falls or blows: body is very cold and can- 
not get warm : headache, with sensation as if the brain were 
bruised; numbness and cramps in the limbs. 

Gelsemium. — Stupid, drowsy condition, with pain in the 
back of the head, dilated pupils, and paralysis of the lower 
sphincters. 

Hyoscyamus. — Second stage, attended with violent reaction, 
and low or furious delirium. 

Lachesis. — Apoplectic symptoms, with low, muttering delir- 
ium, pale face, cold extremities, and paralysis of the left side. 

Liurocerasus. — Loss of consciousness, loss of speech, and loss 
of motion; sunken countenance; slow, feeble pulse ; moaning 



CONCUSSION OF THE BRAIN. 301 

and rattling breathing ; skin cold and blue ; trembling of the 
limbs ; paralysis of the sphincter ani, with unconscious dis- 
charge of faeces. 

Phosphoric acid. — The best remedy, in most cases, for the 
nervous debility remaining after concussion of the brain; fre- 
quent cold spells, with general chilliness; pulse irregular; 
weakness of memory, with confusion of mind ; bruised sensa- 
tion in all the limbs ; dull headache, especially in the fore- 
head and temples; restlessness, with pain in the back, and 
great despondency ; profuse sweating. 

Veratrum alb. — Cold, pale, disfigured face, as of a dead per- 
son ; limbs cold and trembling from weakness ; speechlessness, 
with unperceived discharge of loose faeces ; palpitation of the 
heart, with anxiety, and arrested breathing ; loss of sensation 
and motion ; tendency to collapse. 

Vipera redi. — Sopor, with loss of sight and difficult breath- 
ing ; pulse slow, feeble, and irregular, with coldness and sweat; 
constant disposition to faint ; delirium ; convulsions ; paraly- 
sis of single limbs, or of one-half of the body ; difficulty of 
swallowing ; vomiting and diarrhoea. 



302 INTRACRANIAL DISEASES. 



CHAPTER VII. 

HYDKOCEPHALOID. 

This is the name given by Sir Marshall Hall to a group of 
symptoms closely resembling those of acute hydrocephalus. 
The symptoms are not peculiar to any one disease, though 
most frequently met with in infants that have fallen into an 
anaemic state, in consequence of an exhausting diarrhoea. It 
is but justice to this eminent author to describe the condition 
referred to in his own language : 

" Hydrocephaloid may be divided into two stages : the first, 
that of irritability ; the second, that of torpor. In the former 
there appears to be a feeble attempt at reaction ; in the latter 
the powers appear to be more prostrate. These two stages re- 
semble, in many of their symptoms, the first and second stages 
of hydrocephalus respectively. 

"In the first stage the infant becomes irritable, restless, and 
feverish ; the face flushed, the surface hot, and the pulse fre- 
quent ; there is an undue sensitiveness of the nerves of feeling, 
and the little patient starts on being touched, or on hearing 
any sudden noise; there are sighing and moaning during 
sleep, and screaming ; the bowels are flatulent and loose, and 
the evacuations are mucous and disordered. 

"If through an erroneous notion as to the nature of this affec- 
tion, nourishment and cordials be not given, or if the diarrhoea 
continue, either spontaneously or from the administration of 
medicine, the exhaustion which ensues is apt to lead to a very 
different train of symptoms. The countenance becomes pale, 
and the cheeks cool or cold ; the eyelids are half closed, the 
eyes are unfixed and unattracted by any object placed before 
them, the pupils unmoved on the approach of light; the 



HYDEOCEPHALOID. 303 

breathing, from being quick, becomes irregular and affected 
by sighs; the voice becomes husky, and there is sometimes a 
husky, teasing cough ; and eventually, if the strength of the 
little patient continue to decline, there is a crepitus or rattling 
in the breathing. The evacuations are usually green; the feet 
are apt to be cold." 

If it is important to distinguish this condition as met with 
in anaemic children suffering from summer complaint, it is 
equally so to recognize and properly estimate it when met 
with under other forms. We frequently observe precisely this 
train of symptoms during the initial stage of pneumonia in 
infants, and also in helminthiasis. In fact the irritation caused 
in children by intestinal worms, crude ingesta, and sometimes 
even by cold alone, is not only of the same nature, but appar- 
ently identical with that of hydrocephaloid. This, however, 
is not to be wondered at, since the symptoms mentioned are of 
a purely reflex character. The important point to remember 
is, that symptoms resembling those of acute hydrocephalus 
may present themselves in the course of almost any exhausting 
disease, especially in the case of children, and that in most in- 
stances they simply denote cerebral irritation, and not menin- 
geal inflammation. The point is one of great practical im- 
portance, since the removal of the cause, though far distant 
from the seat of irritation, will generally put an immediate 
stop to the symptoms, as we ver) f often see in the case of infan- 
tile remittent fever. 

Treatment. — It follows from what has just been said, that 
whenever the physician meets with the symptoms of hydro- 
cephaloid, he should, first of all, be careful to make a correct 
diagnosis, with a view to ascertain, and prescribe for, the 
cause, which in the great majority of cases will be found to be 
seated somewhere in the intestinal or respiratory tract. If, 
as very frequently happens, the symptoms are due to ver- 
minous irritation, Cina or Santonine will be found to be a very 
effective remedy; if due to cold, Gelsemium will generally 
relieve ; and if summer complaint be the cause, Mercurius, 
either with or without the more specifically indicated remedy, 
as the case may require, will often allay the intestinal, and 
with it the cerebral irritation. 



304 INTRACRANIAL DISEASES. 

Special Indications. — JEthusa cyn. — Great debility and pros- 
tration, with drowsiness; greenish watery stools in the morn- 
ing, during dentition, with much pain and tenesmus ; vomiting 
of white, frothy matter, or of coagulated milk ; eyes turned up, 
or fixed and staring; face pale, with a painful facial expres- 
sion, especially about the mouth ; child dozes and cries alter- 
nately; or utters piteous moans from time to time; spasms and 
convulsions. 

Apis met. — Thin yellow, or offensive watery diarrhoea in 
teething infants, accompanied by great prostration; hands 
and feet blue and cold ; tenderness of the abdomen on press- 
ure; stools frequent but odorless, generally worse in the 
morning ; urine very scanty or suppressed ; child very feeble 
and drowsy, frequently uttering shrieks or plaintive cries. 

Arsenicum. — Greenish or yellowish stools, often watery, with 
extreme prostration, frequent sinking spells, and violent vomit- 
ing ; child wants to lie with the head low ; great thirst, but 
drinks little at a time, and generally vomits as soon as the 
water becomes warm in the stomach; rapid emaciation; rapid 
and feeble pulse ; dilated pupils ; sunken abdomen ; involun- 
tary stool and urine. 

Belladonna. — Green stool, voluntary or involuntary, followed 
by tenesmus ; head hot and feet cold ; drowsy with frequent 
startings; tongue with red tip and edges; mouth and lips 
dry ; spasms and convulsions. 

Borax ven. — Stools variously colored, painful or painless; 
odorless or cadaverous-smelling ; constant vomiting, gagging, 
and retching; abdomen soft or flabby and sunken; very 
drowsy and emaciated ; child starts as if frightened on being 
lowered into the crib or cradle. 

Bryonia. — Offensive diarrhoea, especially in the morning, or 
after nursing, which the child constantly wants ; lips dry and 
parched ; child turns pale on being disturbed or raised up ; 
very feverish and fretful, especially when disturbed. 

Calcarea phos. — Poor, scrawny-looking children, with dry, 
dirty-white skin, and aged countenance; thin greenish stools, 
with a great deal of offensive flatulence ; pus-like stools, which 
have a cadaverous odor. 



HYROCEPHALOID. 305 

Camphora. — Involuntary watery diarrhoea, with frequent 
vomiting; skin cold and clammy; child appears to be in a 
collapsed state, stupid, senseless, and almost without life; lies 
with its mouth open and the eyes half closed. 

Chamomilla. — Stools watery, green, or like chopped eggs; 
child very restless and wants to be continually carried about 
in the nurse's arms; symptoms produced by cold or teething. 

China. — Painless diarrhoea, worse in the morning ; great de- 
bility, with disposition to faint after every stool; diarrhoea 
increased by frequent nursing; child cries and bends double 
with colic; body alternately hot and cold. 

Cina. — Constipation or diarrhoea in young children, during 
or after dentition, accompanied by a broad white circle or 
space around the mouth and nose, in strong contrast with the 
deep-red cheeks ; high fever, worse towards evening, better in 
the morning; loss of appetite; frequent picking at the nose; 
bloated abdomen; bad breath; starting in the sleep; diarrhoea, 
with greenish, slimy, or white mucous stools; first stage of 
hydrocephaloid. 

Cuprum. — Violent diarrhoea, with vomiting and cramps; 
collapsed condition with sunken features, cold sweat, and 
weak, small pulse ; stools watery, copious, with greenish flakes, 
often accompanied by flatulence; spasms and convulsions. 

Ferri phos. — Frequent green, watery or hashed stools, mixed 
with mucus, and scanty; tenesmus; retching; child moans and 
rolls its head; starts in sleep; face pinched; eyes half open; 
urine scanty; pulse and respiration quickened. 

Helleborus. — Watery or jelly-like stools, with colic and tenes- 
mus; urine scanty and high colored; pale and puffed appear- 
ance of the face; tenesmus; vomiting of mucus, mixed with a 
greenish or blackish watery fluid; great drowsiness, with cold 
sweat; incontinency of urine; swelling of the feet. 

Ignatia. — Sudden development of hydrocephaloid symptoms 
during dentition ; child moans and rolls its head, or screams 
violently, with convulsive action of eyes and lips; face pale; 
great difficulty in swallowing; spasms and convulsions. 

Kreosotum. — Stools greyish-white, chopped, and very offen- 
sive ; great thirst, with constant vomiting ; face cold, with a 

20 



306 INTRACRANIAL DISEASES. 

pale border around the nose and mouth ; child moans and 
starts in sleep ; emaciation and great prostration ; rapid and 
weak pulse ; hurried and feeble respiration. 

Lachesis. — Undigested watery stools, which are very offen- 
sive, accompanied with rumbling in the bowels and violent 
straining; abdomen hot and bloated ; stools sometimes mixed 
with pus. 

Lycopodium. — Loose, brown, or thin, pale stools, also mucous 
stools, green, stringy, and odorless ; abdomen distended with 
gases; pale, wretched complexion; cold feet; drowsy, with 
frequent startings and jerkings of the limbs ; eructations and 
hiccough. 

Phosphorus. — Hydrocephaloid symptoms, with great depres- 
sion of the vital power ; violent watery diarrhoea, with con- 
stant straining ; anus constantly remains open ; stools exces- 
sively foetid ; cold drinks ejected from the stomach as soon as 
they become warm ; emaciation and sudden loss of strength. 

Podophyllum. — Frequent, violent, watery stools, ejected with 
a gush ; painless diarrhoea, with cramps in the legs or feet ; 
stools followed by tenesmus and prolapsus ani ; child moans 
and rolls its head from side to side ; disposed to faint after 
every evacuation of the bowels ; frequent retching and 
vomiting ; worse in the morning, at night, and after taking 
nourishment. 

Sulphur. — Scrofulous children with hydrocephaloid symp- 
toms; stools extremely offensive, slimy, watery, frothy, and 
putrid ; constant thirst, with frequent vomiting ; white tongue, 
with red tip and borders; abdomen distended with flatus; 
great debility and prostration, with difficult breathing, and 
involuntary stools. 

Veratrum alb. — Frequent, profuse, greenish, watery stools, 
with flakes ; violent vomiting, followed by coldness and great 
prostration, with cold sweat on the forehead, and cold tongue; 
extreme thirst, but drinking increases the nausea and diarrhoea; 
collapse, with cold breath and suppression of urine. 

Zincum. — Hydrocephaloid symptoms, with great nervous 
depression ; stools frothy, with or without tenesmus ; during 
sleep the child cries out, starts, and jumps; on awaking it 
appears frightened, and rolls its head from side to side. 



INDEX. 



Abscess, cerebral, 101. 

Acetic acid in nervous beadacbe, 24.4. 

Aconite in cerebral hyperaemia, 87 ; in cere- 
bral haemorrhage, 10S : in simple acute 
meningitis, 175 ; in cerebro-spinal menin- 
gitis, 207; in congestive beadacbe, 232; 
in nervous headache, 24.5; in catarrhal 
and menstrual headaches, 259 ; in ver- 
tigo, 276 ; in insomnia, 2S4 : in sunstroke, 
295. 

Adamiik on the nates, 33. 

iEthusa cyn. in simple acute meningitis, 176 ; 
in hydrocephaloid, 304. 

Agaricus in epidemic meningitis, 207 ; in con- 
gestive headache, 232 ; in nervous head- 
ache, 245. 

Agnus cast, in nervous headache, 245. 

Ailanthus in congestive headache, 232 ; in 
nervous headache. 245. 

Albuminuria. 59. 

Allium cepa in catarrhal headache, 259. 

Aluminum in congestive headache, 232 ; in 
catarrhal headache, 259. 

Althaus, Dr., on arachnitis, 191. 

Amaurosis, 33. 54. 

Ammonium carb. in congestive headache. 232. 

Amyl nitrite in cerebral anaemia, 69 : in cere- 
bral hyperaeinia, S7 ; in congestive head- 
ache, 233 ; in vertigo, 277 ; in sunstroke, 
295. 

Anacardium in nervous headache, 245 ; in 
gastric headache, 259. 

Anarthia, 56. 

Anaemia, cerebral, 62; symptoms of, 63; syn- 
cope in, 64 ; vaso-motor, 65 : paralysis in, 
65 ; causes. 65 ; diagnosis, 67 ; prognosis, 
67 : morbid anatomy, 6S ; pathology, 68 ; 
treatment, 69. 

Andral on cerebral haemorrhage, 104. 

Aneurisms, miliary, 105. 

Angular gyrus, motor centres in, 20, 26 ; re- 
lated to vision, 33. 

Antimonium crud. in gastric headache, 259 ; 
in sunstroke, 295. 

Antimonium tart, in coma, 2S9 : in sunstroke, 
295. 

Aphasia, 42, 44, 123. 

Aphonia, 61. 

Apis mel. in simple acute meningitis, 176; in 
epidemic meningitis, 20S; in congestive 
headache, 233: in nervous headache, 246; 
in hydrocephaloid, 304. 

Aplasia, progressive laminar, 151. 

Apoplexy, central pontine, 59; cerebral, 91-93; 
symptoms, 91; hemiplegia in. 92; causes, 
92; cerebral haemorrhage in, 93. 

Appetite, seat of, 28. 

Arachnitis, 191; symptoms and morbid anat- 
omy, 191; etiology, diagnosis, prognosis 
and treatment, 192. 



Argentum met. in nervous headache, 246; in 
gastric headache, 259. 

Argentum nit. in paralysis of the ciliary 
muscle, 201; in epidemic meningitis, 208; 
in nervous headache. 246 : in vertigo, 
277. 

Arnica in cerebral hyperaemia, S7; in cerebral 
haemorrhage, 10S; in epidemic meningitis, 
20S; in congestive headache, 233; in nerv- 
ous headache, 246; in cerebral concus- 
sion, 300. 

Arsenicum in cerebral anaemia, 70; in simple 
acute meningitis, 176; iu epidemic menin- 
gitis, 208; in chronic hydrocephalus, 222: 
in nervous headache, 246: in sympathetic 
headache. 260; in vertigo. 277: in sun- 
stroke, 295: in hydrocephaloid, 304. 

Articulation, 35, 61; "centre for. 40. 

Asafoetida in nervous headache, 247; in hys- 
terical headache. 259. 

Asarum in nervous headache, 247. 

Asclepias syr. in congestive headache, 233; 
in nervous headache, 247. 

Atheromatous degeneration in cerebral haem- 
orrhage. 105: in cerebral thrombosis, 113. 

Athetosis. 51. 145-150; symptoms, 145: causes, 
diagnosis and prognosis, 149; morbid 
anatomy, pathology and treatment, 150. 

Atrophy, cerebral, 139-142: symptoms. 139; 
partial, 139; general, 140; causes, diag- 
nosis and prognosis, 140; morbid anatomy, 
pathology and. treatment, 141; galvanism 
in, 142: progressive facial, 151. 

Atropine in congestive headache, 233; in 
nervous headache. 247. 

Auditory vertigo, 36, 271. 

Aurum in nervous headache, 24S. 

Automatic movements, 35. 

Baptisia in epidemic meningitis, 203. 

Baryta in cerebral haemorrhage, 10S; in tuber- 
cular meningitis, 1S6. 

Basilar meningitis, chronic, 198; symptoms, 
19S: morbid anatomy, 199; pathology and 
etiology, 200; diagnosis, prognosis and 
treatment. 201; general and special indi- 
cations, 201, 202. 

Basal ganglia, functions of the, 30; lesions 
of. 47. 

Bastion. Dr., on the genital functions, 54; 
on lesions of the cms cerebri, 57; on intra- 
cranial hydatids. 225. 

Bed-sores, acute, 97. 

Belladonna in cerebral hyperaemia, 57: in 
cerebral haemorrhage, 10S; in simple acute 
meningitis, 176; in epidemic meningitis, 
208; in congestive headache, 233; in nerv- 
ous headache, 24S; in sympathetic head- 
ache, 260; in vertigo, 277; in insomnia, 
254: in coma, 2SS; "in sunstroke, 295; in 



308 



INDEX. 



cerebral concussion, 300; in hvdrocepha- 
loid, 304 

Berberis in sympathetic headache, 260. 

Betz on giant cortical cells. 24. 

Bismuth iu gastric headache, 260. 

Blood-clots, intracranial, 104. 

Borax in hydrocephaloid, 304. 

Bouchard on miliary aneurisms, 105. 

Bovista in menstrual headache, 250. 

Broadhent, Dr., theory of, 25. 

Broca's convolution, 21, 29, 42. 

Bromides in cerebral hyperemia, S6. 

Brown-Sequard on cerebral localization, 22 ; 
on crossed paralysis, 23. 

Bryonia in cerebral hyperemia, S7; in simple 
acute meuicgitis, 176 ; in epidemic men- 
ingitis, 210; in congestive headache, 234 ; 
in gastric and rheumatic headaches, 260 ; 
in vertigo, 277: in coma, 2SS ; in sunstroke, 
295 ; in hydrocephaloid, 304. 

Budge on the peristaltic movements of the 
oesophagus and stomach, 37. 

Bulb, functions of the, 3S. 

Cactus in cerebral hyperemia, SS ; in conges- 
tive headache. 234: iu sunstroke. 295." 

Caladium in congestive headache, 234. 

Carville and Buret on functional substitution, 
25; on heinianaesthesia, 31. 

Calcarea carb. in tubercular meningitis. 187; 
in chronic hydrocephalus, 222 ; in conges- 
tive headache. 234 ; in nervous headache, 
24S; in vertigo, 278. 

Calcarea phos. in tubercular meningitis, 1S7; 
in chronic hydrocephalus, 222; in gastric 
and rheumatic headaches, 260; in hydro- 
cephaloid, 304. 

Calmeil on the morbid anatomy of cerebral 
hyperemia, S4. 

Camphora iu cerebral anaemia, 70: in epidemic 
meningitis. 210; iu congestive headache, 
234; in coma. 2SS; in sunstroke, 295; iu 
hydrocephaloid, 305. 

Cancer, cerebral, 15S. 

Cannabis ind. in epidemic meningitis, 210. 

Cantharadis iu simple meuiugitis, 177; in epi- 
demic meningitis, 210. 

Capsicum in congestive headache, 234. 

Carbo an. in congestive headache, 235; iu 
menstrual headache, 261. 

Carbo veg. in congestive headache, 235: in 
suustroke, 295. 

Cardiac affections, 100. 

Cardio-inhibitory centre, 3S. 

Caulophyllum in nervous headache, 245: iu 
menstrual and rheumatic headaches, 261. 

Causticum in ocular paralysis, 201; in conges- 
tive headache. 235: in nervous headache, 
24S; in arthritic and rheumatic headaches, 
261; in vertigo, 278. 

Cedron in malarial headache, 261. 

Cephalagia, 230-250. 

Centrum ovale, lesions of, 46. 

Cerebellum, functions of, 35; lesions of, 57,58. 

Cerebrum, functions of, 17. 

Cerebral cortex, motor centres in, 17-26, 38; 
sensory centres in, 26-2S. 

Cerebral ganglia, functions of, 30-32; lesions 
of, 47. 

Cerebral lesions, 41. 

Cerebritis, 130. 

Cerebro-spinal isthmus, lesions of, 57. 

Cerebro-spinal meningitis, 202-210: symptoms, 
203; complications and sequelee. 204; mor- 
bid anatomy and pathology, 205; etiology 
and diagnosis, 206; prognosis and treat- 
ment, 207; special indications, 207-210. 

Chamomilla in congestive headache, 235; in 
nervous headache, 24S; in arthritic and 



rheumatic headaches, 261; in coma, 2SS; 
in hydrocephaloid, 305. 

Charcot on secondary contractions, 99; on 
miliary aneurisms, 105; on the vascular 
system of the brain, 42, 47, 57; on the basal 
ganglia, 47. 

China in cerebral anaemia, 70; in epidemic 
meningitis, 210 ; in congestive headache, 
236; in nervous headache, 249; iu vertigo, 
278; hydrocephaloid, 305. 

Chelidonium in bilious headache, 262. 

Chloralum in nervous headache, 249. 

Cholesteatoma, 157. 

Chorea, 146; post-hemiplegic, 149. 

Cicuta in epidemic meningitis, 210; in nervous 
headache, 249; in vertigo, 27S; in cerebral 
concussion, 300. 

Cimicifnga in cerebral hyperemia, SS; in epi- 
demic meningitis, 210; in congestive head- 
ache, 236; in nervous headache, 249. 

Cina in cerebral anaemia, 71; in simple menin- 
gitis, 177; in hydrocephaloid, 305. 

Clark, Dr., on the vaso-motor centre, 39. 

Cocculusin cerebral haemorrhage, 10S; in epi- 
demic meningitis, 211; in congestive head- 
ache, 236 ; in nervous headache, 250 : in 
gastric and menstrual headaches, 262; in 
vertigo. 27S: in iusomnia, 2S4. 

Coffea in nervous headache, 250; in cerebral 
hyperemia, SS; in insomnia, 2S4. 

Cohnheim on cerebral softening, 127. 

Colocynthis in nervous headache, 250; in ar- 
thritic and rheumatic headaches, 262. 

Coma, 100, 101, 256-259; hysterical, 102; urae- 
mic, 192; symptoms. 2S6: diagnosis, 256: 
causes. 2^7: prognosis, 2>7; treatment. 257: 
special indications, 2SS. 

Concussion, cerebral, 102, 297-301; symptoms, 
297; morbid anatomy, 29S; patko'logy, 298; 
prognosis, 29S; treatment, 299: general in- 
dications, 299; special indications, 300. 

Coordination, optic, 34, 52: pontine, 35; cere- 
bellar, 36, 55; reflex, 38; general centre 
for, 40. 

Contractions, late, 48, 99. 

Convulsive centre, 38; lesions of, 44. 46. 

Consciousness, intelligent, seat of, 29. 

Convexital meningitis, chronic, 195: symp- 
toms, 195: morbid anatomy and pathology, 
196; etiology and diagnosis, 197; prognosis 
and treatment, 19S. 

Corpora quadrigemina, functions of, 33. 

Corpora striata, functions of, 30, 32; lesions 
of, 45. 49. 52. 

Cortical lesions. 45. 

Crocus in menstrual headache, 262. 

Colchicum in vertigo, 278. 

Conium in vertigo, 27S; in cerebral concus- 
sion, 300. 

Crotalus in epiilemic meningitis, 211; in nerv- 
ous headache, 250. 

Crura cerebri, functions of, 34: lesions of, 
57, 60. 

Cuprum in simple meningitis, 177: in paraly- 
sis of the nervus abduceutis, 202; in epi- 
demic meningitis, 211; in congestive head- 
ache, 236: in vertigo, 279; in hydrocepha- 
loid, 305. 

Cysticerci, cerebral, 227. 

Deglutition, centre for, 39. 

Devaine and Cobbold on intracranial hyda- 
tids, 225. 

Diabetic centres, 37, 40, 59. 

Digitalis in simple meningitis, 177: in epi- 
demic meningitis, 211; in congestive head- 
ache. 236. 

Dittmer on the vaso-motor centre, 39. 

Dowse, Dr., on cerebral syphillis, 164, 167, 169. 



INDEX. 



309 



Dropsy, cerebral, 21S-224: symptoms, 218; mor- 
bid anatomy and pathology, 217; causes, 
221; diagnosis, 221: prognosis and treat- 
ment, 222; special indications, 222-224. 

Dulcamara in congestive headache, 236. 

Durand-Fardel on the morbid anatomy of cer- 
ebral hyperemia, S4. 

Dnret and Carville on functional substitu- 
tion, 2-5. 

Eckard on vicarious action, 22; on excitable 

cortical fibres, 23. 
Electrical stimulation of the cerebral cortex, 

17-40. 
Embolism, cerebral, 101, 116; symptoms, 116; 

causes, 117; diagnosis and prognosis. US; 

morbid anatomy and pathology, 119, treat- 
ment, 120. 
Emotional centres, 33, 39, 60. 
Emotional weakness, 60. 
Encephalitis, 130; symptoms, 130-133; causes, 

133; diagnosis and prognosis, 134; morbid 

anatomy and pathology, 13.5: treatment, 

136. 
Epidemic meningitis, 202. 
Epileptic moaning and crying, 34, 38. 
Epileptiform convulsions, 46, 59, 159, 160. 
Ergot in cerebral hyperemia, S6. 
Equilibrium, disorders of. 35, 36, 52. 
Eupatorium perf. in bilious ' and malarial 

headaches, 262. 
Euphrasia in paralysis of the oculo-motor 

nerve, 202; in catarrhal headache, 262; 

in vertigo, 279; in cerebral concussion, 

300. 
Eyes, centres for the movements of the, 20. 

Facial atrophy, progressive, 151-153: symp- 
toms, 151; "etiology, diagnosis and pathol- 
ogy, 152; treatment, 153. 

Facies hydrocephalica, 220. 

Ferrier on cortical centres and lesions, pas- 
sim; his methods of research, 19, 20. 

Ferrum in cerebral anemia, 71; in congestive 
headache, 236: in hydrocephaloid, 305. 

Fleming on cerebral anemia, 6S. 

Fluroric acid in congestive headache, 237 

Foreign products, intracranial. 22.5-229: symp- 
toms, 227-22S; prognosis, 22S: treatment, 
229. 

Formica in nervous headache, 250. 

Fritsch and Hitzig on cerebral centres, 17. 

Functional substitution, law of, 26. 

Functions of the cerebral hemispheres, 77; of 
the cerebral ganglia, 30. 

Fungus dure matris, 15S. 

Galvanism in cerebral anaemia, 69; in cere- 
bral hyperemia, 85: in cerebral atrophy, 
142. 

Gamboge in gastric headacbe, 262. 

Ganglia, basal, 30. 

Gastric and cesophagal centre, 39. 

Gelsemium in cerebral hyperemia, SS; in 
simple meningitis, 177; in paralysis of 
the ocular muscles, 202; in epidemic 
meningitis, 211; in congestive headache, 
237; in nervous headache, 251; in catarrhal 
and hysterical headaches, 263; in vertigo, 
279; in insomnia, 284; in cerebral concus- 
sion, 300. 

Giacomini on the human measle, 22S. 

Giant-pyramidal cells in the cerebral cortex, 
24. 

Glioma. 157. 

Glonoin in cerebral hyperemia, S8; in simple 
meningitis, 177; in epidemic meningitis, 
212; in congestive headache, 237; in nerv- 
ous headache, 251; in sunstroke, 295. 



Goltz on cortical paralysis, 23; his method of 

research: 20. 
Gossypium in menstrual headache, 263. 
Graphites in nervous headache, 251. 
Gratiolain congestive headache, 237. 
Gumma syphiliticum, 169. 
Gymnocladus in congestive headache, 237; in 

catarrhal headache, 263. 

Hammond, Dr., on cerebral diseases, passim; 
on strong magnets in hemiplegia. 107. 

Hamamelis in congestive headache, 238. 

Headache, 230-26S; congestive 231; nervous, 
243; sympathetic, 257. 

Hearing, centre for, 26. 

Helleborus in simple meningitis, 178; in 
chronic hydrocephalus, 223; in coma, 2SS; 
in hydrocephaloid, 305. 

Heminesthesia, 31, 47-50. 

Hemichorea, 50, 51. 

Hemiopia, 44; homonymous, 51. 

Hemiplegia, partial, 45; from lesion of the 
basal ganglia. 47. 50; from lesion of the 
crus cerebri, 55; pontine, 5S; in cerebral 
apoplexy, 92, 94, 97; causes, 99; diagnosis, 
100; prognosis, 102; morbid anatomy, 103; 
pathology, 105; treatment, 105: general 
indications, 107; special indications, 108. 

Hermann on vicarious action, 22; on cortical 
paralysis, 24. 

Heubner on cerebral thrombosis, 114; on 
cerebral syphilis, 164, 170. 

Hensen on the corpora quadrigemina, 33. 

Hemorrhage, cerebral, 93; symptoms, 93; 
apoplectic, 94; temperature" in, 96; local- 
ization of, 93 

Hematoma. 214-217; symptoms, 214; morbid 
anatomy and pathology, 215; causes, 216; 
diagnosis, 216; prognosis and treatment, 
217. 

His on perivascular canals, S4. 

Hitzig on cerebral centres, 17; his method of 
research, 19; on temperature, 29. 

Huguenin on hematoma, 216. 

Hydatids, cerebral. 22S. 

Hydrastis in nervous headache, 251; in ca- 
tarrhal headache, 263. 

Hydrocephaloid, 302-306; symptoms, 302; 
diagnosis and treatment, 303; special in- 
dications, 304. 

Hydrocephalus, acute, 179-1SS; symptoms, 
179-1S2; prodromic stage, 179;" stage of 
excitement, ISO; stage of depression, 181; 
closing stage. 182; morbid anatomy, 182; 
pathology and etiology, 1S3; diagnosis, 
1S4; prognosis, 1S5; treatment, 1S6; gen- 
eral and special indications, 1S6-1SS: 
chronic. 21S-224. 

Hydrocvanic acid in epidemic meningitis, 
212.* 

Hyoscyamus in cerebral hyperemia, S8; in 
simple meningitis, 178; in epidemic men- 
ingitis, 212; in nervous headache, 251; 
in vertigo, 279: in insomnia, 2S4; in cere- 
bral concussion, 300. 

Hypertrophy, cerebral, 137; symptoms, 137; 
etiology, diagnosis, prognosis, morbid 
anatomy, pathology and treatment, 13S. 

Hyperemia, cerebral, 73-87; symptoms, 73; 
cardiac disturbances in, 76;" varieties of, 
7S; delirium in, 78; convulsive and apo- 
plectic forms of, 79; causes, SO; diagnosis, 
SI; prognosis, S2; morbid anatomy. S3; 
pathology. S4; treatment, 85; general in- 
dications, 86; special indications, S7. 

Hyperesthesia, unilateral, 59. 

Hysteria, 60. 

Ignatia in nervous headache, 252; in vertigo, 



310 



INDEX. 



279; in insomnia, 284; in hydrocephaloid, 
305. 

Incoordination, 40, 55, 145. 

Insomnia, 282-285: symptoms, 282; treatment 
and general indications, 283; special in- 
dications, 2S4. 

Internal capsule, lesions of, 47, 49, 50. 

Iodine in congestive headache, 238. 

Ipecacuanha in cerebral anaemia, 71; in nerv- 
ous headache, 252; in gastric headache, 
263; in vertigo, 279. 

Iris vers, in nervous headache, 252; in 
bilious and gastric headaches, 263. 

Jacobi on cerebral anaemia, 68. 
Jaws and tongue, centre for, 21. 

Kali bich. in catarrhal and rheumatic head- 
aches, 263. 

Kali carb. in congestive headache, 238; in 
catarrhal headache, 264. 

Kali iod. in tubercular meningitis, 187; in 
paralysis of ocular muscles, 202; in 
chronic hydrocephalus, 223; in conges- 
tive headache, 238; in catarrhal head- 
ache, 264; in vertigo, 279. 

Kalmia in vertigo, 279. 

Kolliker on the arachnoid, 191. 

Kreosotum in hydrocephaloid, 305. 

Krishaber on cardiac disturbances in cerebral 
hyperemia, 76. 

Kussmaul and Tenner on faradization of the 
cervical sympathetic, 6S. 

Lachesis in cerebral haemorrhage, 108; in 
chronic hydrocephalus, 223; in congestive 
headache, 238; in sympathetic headache, 
266; in vertigo, 279; in coma, 288; in cere- 
bral concussion, 300; in hydrocephaloid, 
306. 

Lachnanthes in congestive headache, 239. 

Landouzy on athetosis, 150. 

Landois on temperature, 29. 

Language, centre for, 29. 

Lateral sinuses, thrombosis of the, 226. 

Laurocerasus in cerebral haemorrhage, 109; 
in cerebral concussion, 300. 

Lepto-meningitis, cerebral, 172; tubercular, 
179; traumatic, 193; symptoms and morbid 
anatomy, 193; pathology, prognosis and 
treatment, 194. 

Lesions, diagnostic, 41; systemic, 42; latent, 
44; irritative, 46; ganglionic, 47; cerebel- 
lar, 53. 

Lilium tig. in congestive headache, 239; in 
menstrual headache, 264. 

Lips and mouth, centres for the, 21. 

Longet, hypothesis of, 26; on the optic thala- 
mus, 32. 

Longitudinal sinus, thrombosis of the, 226. 

Lower extremity, centres for the, 22. 

Lussana and Lemoigne on the cortical centres, 
23; on the optic thalamus, 32. 

Lycopodium in tubercular meningitis, 1S7; in 
epidemic meningitis, 212; iu congestive 
headache, 239; in sympathetic headaches, 
264; in hydrocephaloid, 306. 

Magnesia carb. in congestive headache, 239. 

Mai-antic thrombosis, 112. 

Medulla oblongata, lesions of, 60. 

Meningeal affections, 117-209. 

Meningitis, simple acute, 171-17S; 'symptoms, 
171; morbid anatomy, 173; pathology, eti- 
ology and diagnosis, 174; prognosis, treat- 
ment and general indications, 175; special 
indications, 176-178; tubercular, 179; trau- 
matic, 1S9-194; chronic, 195-202; convexi- 
tal, 195; basal, 198; epidemic, 203. 



Mental disorder, 43. 

Mercurius in cerebral hyperaemia, 88; in cere- 
bral haemorrage, 109; in simple meningitis, 
178; in paralysis of ocular muscles, 202; 
iu chronic hydrocephalus, 223; in conges- 
tive headache, 239; in catarrhal and rheu- 
matic headaches, 264. 

Meso-cephalon, functions of, 34. 

Meynert on cerebral ganglia, 30, 32. 

Mezereum in catarrhal headache, 265. 

Miliary aneurisms, 105. 

Moaning and crying, epileptic, 34. 

Monkey, experiments on the, 20. 

Monoplegia, 45. 

Moschus in insomnia, 284. 

Motor centres, cortical, 17-40; tracts, 38. 

Motor-oculi nerve, paralysis of, 34. 

Mouth and lips, centre for, 21. 

Multiple sclerosis, primary, 143-147; secon- 
dary, 146-147. 

Muscular coordination, 34-54; rigidity, 46, 60. 

Myxcedema, 154; symptoms, 154, diagnosis, 
prognosis and pathology, 155; treatment, 
156. 

Naja in congestive headache, 240. 

Nates, functions of, 33; lesions of, 51, 52. 

Natrum mur. in cerebral anaemia, 71; in nerv- 
ous headache, 252; in menstrual headache, 
265; in vertigo, 279. 

Natruin sulph. in congestive headache, 239; 
in menstrual headache, 265. 

Neuroma, 157. 

Nceud vital, 38. 

Nitric acid in congestive headache, 240. 

Nitrite of amyl in cerebral anaemia, 69; in 
cerebral hyperaemia, 87. 

Nothnagel on the basal ganglia, 49-52; on 
cerebellar lesions, 55, 56; on lesions of 
the cms cerebri, 57; on lesions of the 
medulla oblongata, 60, 61; on cerebral 
anaemia, 68. 

Nux mosch. in hysterical headache, 265; in 
coma, 288. 

Nux vomica in cerebral anaemia, 71; in cere- 
bral hyperaemia, 89; in cerebral haemor- 
rhage, 109; in paralysis of ocular muscles, 
202; in epidemic meningitis, 212; in con- 
gestive headache, 240; in nervous head- 
ache, 253; in gastric and bilious head- 
aches, 265: in vertigo, 280; in insomnia, 
2S4. 

Nystagmus, 112. 

Ocular troubles in cerebral thrombosis, 112. 
Opium in cerebral hyperaemia, S9; in cerebral 

haemorrhage, 109; in simple meningitis, 

178; in vertigo, 280; in paralysis of ciliary 

muscle, 202; in epidemic meningitis, 212; 

in congestive headache, 240; in insomnia, 

284; in coma, 2S8. 
Optic ganglia, 33, 51. 
Optic thalami, functions of, 31; lesions of 

49-51. 
Ord, Dr., on myxcedema, 154. 
Oulmont and Brousse on double athetosis, 

149. 
Ocular troubles in cerebral thrombosis, 112. 

Pachymeningitis, 189-191; symptoms, 189; 

treatment, 190; hemorrhagic, 214-217. 
Pagenstecher on cerebral compression, 84. 
Pain, occipital, 53. 
Paracentral lobule, lesion of, 46. 
Paralysis, cortical, 24, 25, 45; facial, 34, 35, 

45, 59. 
Parasites, cerebral, 227. 
Paris quad, in paralysis of the iris and ciliary 

muscle, 202. 



INDEX. 



311 



Petroleum in nervous headache, 253. 

Phosphorus in cerebral hypersemia, 89; in 
paralysis of ocular muscles, 202; in epi- 
demic meningitis, 213; in chronic hydro- 
cephalus, 223; in congestive headache, 
240; in nervous headache, 253; in hysteri- 
cal headache, 265: in vertigo, 2S0; in in- 
somnia, 2S4; ia hydrocephaloid, 306. 

Phosphoric acid in congestive headache, 241; 
in hysterical headache, 266; in vertigo, 
280; in coma, 288; in cerebral concussion, 
301. 

Phytolacca in gastric and rheumatic head- 
ache, 266. 

Physiological considerations, 17. 

Physostigma in vertigo, 2S0. 

Piorry on heredity, 99. 

Platina in nervous headache, 253; in hysteri- 
cal headache, 266. 

Plumbum in epidemic meningitis, 213; in 
chronic hydrocephalus, 223. 

Podophyllum" in sympathetic headache, 266; 
in hydrocephaloid, 306. 

Polyuria, 60. 

Pons Varolii, functions of, 34; lesions of, 58, 60. 

Priapism, 37. 

Psammoma, 157. 

Psorinum in chronic hydrocephalus, 224; in 
congestive headache, 241. 

Pulsatilla in cerebral hyperemia, 89; in cere- 
bral haemorrhage, 109; in congestive head- 
ache, 241; in nervous headache, 254: in 
sympathetic headaches, 266; in vertigo, 
280; in insomnia, 2S4; in coma, 288. 

Reflex coordination, 3S. 

Regional diagnosis in brain diseases, 41; mat- 
ters relating to, 17-32. 

Respiratory centre, 38. 

Rhus rad. in nervous headache, 254. 

Rhus tox. in cerebral hyperaemia, 89; in sim- 
ple meningitis, 178; in paralysis of ocular 
muscles, 202; in epidemic meningitis, 213: 
in nervous headache, 254; in coma, 28S. 

Ringer, Dr., on the causes of athetosis, 149; 
on the pathology of athetosis, 150. 

Robin on perivascular canals, 84. 

Rotation, uniform, 55, 56. 

Rumex in catarrhal headache, ^267. 

Salivary centre, 40. 

Sanguinaria in cerebral haemorrhage, 110; in 
congestive headache, 241; in nervous 
headache, 254; in gastric and rheumatic 
headaches, 267. 

Sanderson, Dr., experiments of, 30. 

Schiff on vicarious action, 22; on a very acute 
form of intestinal inflammation, 37. 

Sclerosis, diffuse cerebral, 139; primary mul- 
tiple, 143; symptoms, 143, 144; tremor in, 
144, 145; causes, 145; diagnosis, prognosis 
and morbid anatomy, 146; secondary mul- 
tiple sclerosis, 147; pathology and treat- 
ment, 147. 

Scutellaria in nervous headache, 255; in hys- 
terical headache, 267. 

Secale cor. in cerebral anaemia, 72; in coma, 
289. 

Secondary degeneration, 46. 

Sensory centres, 26-28; sensory tracts, 3S. 

Sensory disturbances, 44. 

Senega in paralysis of ocular muscles, 202; in 
vertigo, 2S1. 

Sepia in cerebral haemorrhage, 110; in con- 
gestive headache, 242; in nervous head- 
ache, 255; in sympathetic headache, 267; 
in vertigo, 281. 

Serum, intracranial, 225. 

Sexual appetite, centre, 37, 54. 



Silicea in tubercular meningitis, 1S7; in 
chronic hydrocephalus, 224; in congestive 
headache, 242; in nervous headache, 255; 
in gastric and rheumatic headaches, 267; 
in vertigo, 2S1. 

Smell and taste, centre for, 27. 

Softening, cerebral, 115, IIS, 121; symptoms, 
121-124; etiology, diagnosis and prognosis, 
125; red, yellow and white, 122; morbid 
anatomy and pathology, 126; treatment, 
127; general and special indications, 128. 

Spigelia in paralysis of ocular muscles, 202; 
in nervous headache, 255; in vertigo, 281. 

Spongia in tubercular meningitis, 1S8; in con- 
gestive headache, 242. 

Sticta in nervous headache, 256. 

Stillingia in catarrhal headache, 267. 

Stomach and oesophagus, centre for, 37, 39. 

Strabismus, 58, 112. 

Stramonium in cerebral haemorrhage, 110; in 
simple meningitis, 178; in paralysis of 
ocular muscles, 202; in congestive head- 
ache, 242; in nervous headache, 256; in 
hysterical and rheumatic headaches, 267; 
in vertigo, 2S1; in insomnia, 285; in coma, 
2S9. 

Sturges, Dr., on athetosis, 150. 

Sulphur in cerebral anaemia, 72; in simple 
meningitis, 17S; in chronic hyrocephalus, 
224; in congest-ive headache, 242; in nerv- 
ous headache, 256; in catarrhal and gas- 
tric headaches, 268: in vertigo, 281; in in- 
somnia, 2S5; in hydrocephaloid, 306. 

Sunstroke, 290-296; varieties, 290; syncopal, 
290; asphyxial, 291; hyperpyrexia!, 291: 
morbid anatomy. 292; etiology, prognosis 
and treatment. 293; general indications, 
294; special indications, 295. 

Syphilis, cerebral, 164-170; varieties, 164; 
symptoms, 165; causes, 166; diagnosis, 
167; prognosis, 168; morbid anatomy and 
pathology, 169; treatment, 170. 

Syphilitic thrombi, 114, 167. 

T&che cerebrale, 1S4. 

Tactile sensibility, centre for, 27. 

Taste and smell, centre for, 27. 

Tarantula in nervous headache, 256; in ver- 
tigo, 281. 

Temperature, variations in, 43, 59; in cerebral 
haemorrhage. 96; in cerebral softening, 
122; in tubercular meningitis, 1S1; in epi- 
demic meningitis, 204; in sunstroke, 291. 

Testes, lesions of, 51. 

Theridion in congestive headache, 243; in nerv- 
ous headache, 256. 

Thrombosis, cerebral, 101, 111; symptoms, 
111; marantic, 112; causes, 112; diagnosis, 
prognosis and morbid anatomy, 113; pa- 
thology, 114; venous, 226. 

Thuja in nervous headache, 256. 

Tongue and jaws, centre for, 21. 

Tophus syphiliticum, 169. 

Tremor, unilateral, 51; in multiple sclerosis, 
144. 

Trismus, 60. 

Trousseau on tubercular meningitis, 184, 185. 

Tumors, cerebral, 101, 157; tuberculous, 15S; 
cancerous, 15S; gliomatous, 157; symp- 
toms, 15S; causes and diagnosis, 160, 161, 
prognosis, morbid anatomy and pathology, 
161; treatment, 162; general indications, 
163. 

Tiirck on secondary contractions, 99. 

Upper extremity, centres for the, 21, 22. 

Yaso-motor disturbances, 39, 50, 60; in cere- 
bral anaemia, 65. 



312 



INDEX. 



Vcratrum alb. in cerebral anaemia, 72; in epi- 
demic meningitis, 213; in nervous head- 
acbe, 2o7; in vertigo, 281; in coma, 2S9; 
in cerebral concussion, 301; in hydro- 
cepbaloid, :306. 

Veratrum vir. in cerebral hyperemia, 90; in 
epidemic meningitis. 213; in congestive 
headache, 243; in nervous headache, 257; 
in insomnia, 2S5; in sunstroke, 296. 

Vertigo. 36, 55, .56, 269-273; etiology and pa- 
tbology, 271; varieties, 271; auditory, 271; 
ocular, 273; gastric, 27-1: nervous, 275; 
intracranial, 276; treatment, 276; general 
and special indications, 276-2S1. 

Vipera redi in cerebral concussion, 301. 

Visceral sensibilities, seat of, 2S. 

Vision, true centres of, 33; impairment of, 54, 
56; double, 58. 



VircliDW on cerebral thrombosis, 113; on gli- 
oma, 157; on hematoma, 215. 

Voelkers on the corpora qnadrigemina, 33. 

Volition. Beat of, 29; huw differentiated, 43. 

Vomiting, centre for the act of, 39: cerebellar, 
53, 55. 

Vulpian on systemic lesions, 42; cerebellar 
lesions, 55; on secondary contractions, 99; 
on progressive facial atrophy, 152. 

Word-deafness, 44. 

Zincum met. in cerebral haemorrhage, 110; in 
epidemic meningitis, 213; in chrooic hy- 
drocephalus, 224; in nervous headache, 
257; in hydrocephaloid, 306. 

Zincum valer. in insomnia, 2S5. 



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fancies, theories or hypotheses. Of course even-body has a copy of the ' Encyclopedia,' and 
now everybody will get a copy of the Index. We cannot pretend to review such a work. 
It bears every mark of care, capability and conscientiousness, and to hunt about for specks 
of dirt on such a grand picture is not the kind of work for us. The only piece of advice 
we offer to intending purchasers is that they ask for it bound in leather, for common cloth 
binding, no matter how nice to the eye, soon begins to tear at the back, and becomes the 
source of endless annoyance. This applies, of course, to a work for frequent reference, 
and Allen's ' Index ' is practically a dictionary to his ' Encyclopedia,' and as such will be 
used many times a day." — From the Homoeopathic World. 

ALLEN AND NORTON. Ophthalmic Therapeutics. See Nor- 
ton's Ophthalmic Therapeutics. 

ALLEN, WILLIAM A. Repertory of the Symptoms of Inter- 
mittent Fever. Arranged by William A. Allex. 107 pages. 12mo. 

Cloth. Price, Sl.OO 

We give a letter of Timothy F. Allen, M.D., recommending the publication 

of this little work : 

" I have carefully examined the repertory of Dr. Wm. Allen, of Flushing, and assure 

you that it is exceedingly valuable. It should be printed in pocket form. I should use it 

constantly. Dr. Allen has a large experience in the treatment of intermittents, and his 

own observations are entitled to great respect." 

BAEHR, DR. B. The Science of Therapeutics according to the 
Principles of Homoeopathy. Translated and enriched with numer- 
ous additions from Kafka and other sources, by C. J. Hemfel, M.D. 
Two volumes. 1387 pages. Half morocco, .... S9.00 
" The descriptions of disease — no easy thing to write — are always clear and full, some- 
times felicitous. The style is easy and readable, and not too prolix. Above all, the rela- 
tions of maladies to medicines are studied no less philosophically than experimentally, with 
an avoidance of abstract theorizing on one side, and of mere empiricism on the other, which 
is most satisfactory." — From the British Journal of Homoeopathy. 

BELL and LAIRD, DRS. The Homoeopathic Therapeutics of 

Diarrhoea, Dysentery, Cholera, Cholera Morbus, Cholera Infantum, and 
all other Loose Evacuations of the Bowels; by James B. Bell, M.D. 
Second edition. 275 pages. 12mo. Cloth, . . . $1.50 

"This little book, issued in 1869, by Dr. Bell, has long been a standard work in 
Homoeopathic Therapeutics. We feel quite within bounds in asserting that it has been the 
means under our law, of saving thousands of lives. Than this no greater commendation 
could be penned. ... In this second edition, Dr. Bell has been assisted by Dr. Laird, 
of Maine ; also by Drs. Lippe, William P. Wesselhoeft and E. A. Farrington. Thirty- 
eight new remedies are given; the old text largely re-written; many rubrics added to 
the repertory; a new feature, the 'black type,' for especially characteristic symptoms, 
introduced. 

" This is a typical homoeopathic work, which no homoeopathic physician can afford to 
be without. The typographical setting is worthy of the book." — From the Homozopaihic 
Physician. 

EERJEAU, J. PH. The Homoeopathic Treatment of Syphilis, 
Gonorrhoea, Spermatorrhoea, and Urinary Diseases. Revised, 
with numerous additions, bv J. H. P. Frost, M.D. 256 pages. 12mo. 
Cloth, . . . $1.50 

" This work is unmistakably the production of a practical man. It is short, pithy, and 
contains a vast deal of sound practical instruction. The diseases are briefly described ; the 
directions for treatment are succinct and summary. It is a book which might with profit 
he. consulted by all practitioners of homoeopathy." — North American Journal. 



HOMOEOPATHIC PUBLICATIONS, 6 

BREYFOGLE, DR. W. L. Epitome of Homoeopathic Medi- 
cines. 383 pages, $1.25 

We quote from the author's preface : 

" It has been my aim, throughout, to arrange in as concise form as possible, the leading 
symptoms of all well-established provings. To accomplish this, I have compared Lippe's 
Mat. Med. ; the Symtomen-Codex ;. Jahr's Epitome ; Bcenninghausen's Therapeutic Pocket- 
Book, and Hale's New Kemedies. 

BRIGHAM, DR. GERSHAM N. Phthisis Pulmonalis, or Tuber- 
cular Consumption. Pp. 224. 8vo. Cloth. Price, . . $2.00 

This interesting work on a subject which has been the "Opprobrium Med- 
icorum" for generations past, has met with a favorable reception at the hands 
of the profession. It is a scholarly work and treats its subject from the stand- 
point of pure homoeopathy. 

" Just now a fresh move of interest in consumption is passing over the world, and hence 
we may say Dr. Brigham's monograph comes apropos; but on the other hand it comes too 
early, as the parasitic nature of phthisis is now the great phthisiological question which be- 
littles and dwarfs every other. 

"Our author's work must be pronounced as decidedly able, and its principal defects are 
those of the subject itself in its present state of development. In our opinion the whole 
question is still involved in too much doubt and difficulty to admit of its being handled very 
lucidly at present. Dr. Brigham tries very hard to clear the deck of all notions that might 
be in the way of handlinK the subject scientifically, but he does not quite succeed even in 
defining clearly one single form of phthisis. Why? because in the present state of the sub- 
ject it is impossible for any man to do so, and we question whether a much better book on 
phthisis is possible at present." — From, The Homoeopathic World, for October, 1882. 

BRYANT, DR. J. A Pocket Manual, or Repertory of Homoeo- 
pathic Medicine, Alphabetically and Nosologically arranged, which 
may be used as the Physicians' Vade-mecum,, the Travellers' Medical Com- 
panion, or the Family Physician. Containing the Principal Remedies for 
the most important Diseases; Symptoms, Sensations, Characteristics of 
Diseases, etc. ; with the principal Pathogenetic Effects of the Medicines on 
the most important Organs and Functions of the Body, together with 
Diagnosis, Explanation of Technical Terms, Directions for the Selection 
and Exhibition of Remedies, Rules of Diet, etc. Compiled from the best 
Homoeopathic authorities. Third edition. 352 pages. 18mo. Cloth, $1.50 

DR. BURNETT'S ESSAYS. Ecce Medicus; Natrum Muriati- 
cum ; Gold; The Causes of Cataract; Curability of Cataract; 
Diseases of the Veins; Supersalinity of the Blood. Pp. 296. 

8vo. Cloth. Price, $2.50 

Dr. Burnett's essays were so favorably received in this country, that they 
would undoubtedly have commanded a very large sale, had they not been so 
high in price. As it was the six essays would have cost over five dollars, and 
in order to bring them within reach oi' the many we reprinted them, by special 
arrangement with the author, who contributed a new essay, "The Causes of 
Cataract," not hitherto published, and a general introduction to the volume. 

The book is printed in good style on heavy toned paper and well bound, 
and we are able to furnish it at less than half the price of the imported volumes. 
We feel sure that these suggestive and sprightly monographs will be highly 
appreciated by the profession at large. 

BUTLER, DR. JOHN. A Text-Book of Electro-Therapeutics 

and Electro-Surgery; for the Use of Students and General 
Practitioners. By John Butler, M.D., L.R.C.P.E., L.R.C.S.L, etc., 
etc. Second edition, revised and enlarged. 350 pages. 8vo. Cloth, $3.00 



4 F. E. BOERTCKES 

"Among the many works extant on Medical Electricity, we have seen nothing that 
eomes so near 'filling the bill' as this. The book is sufficiently comprehensive for the stu- 
dent or the practitioner. The fact that it is written by an enthusiastic and very intelligent 
homceopathist, gives to it additional value. It places electricity on the same basis as other 
drugs, and points out by specific symptoms when the agent is indicated. The use of elec- 
tricity is therefore clearly no longer an exception to the law of similia, but acts curatively 
only when tised in accordance with that law. We are not left to conjecture and doubt, but 
can clearly see the specific indications of the agent, in the disease we have under ol 
tion. The author has done the profession an invaluable service in thus making plain the 
pathogenesis of this wonderful agent. The reader will find no difficulty in followh _ 
the pathology and treatment of the cases described. Electricity is not held up as the cure- 
all of disease, but is shown to be one of the most important and valuable of remedial agents, 
when used in an intelligent manner. We have seen no work which we can so heartily 
recommend as this." — Cincinnati Medical Advance. 

BUTLER, DR. JOHN. Electricity in Surgery. Pp. 111. 12mo. 
Cloth. Price, $1 00 

Tins' interesting little volume treats on the application of Electricity to 
Surgery. The following are some of the subjects treated of: Enlargement of 
the Prostate; Stricture; Ovarian Cysts; Aneurism; Naevus; Tumors; 
Ulcers; Hip Disease; Sprains; Burns; Galvano-Cautery ; Hemor- 
rhoids; Fistulye; Prolapsus of Kectum; Hernia, etc., etc. The direc- 
tions given under each operation are most explicit and will be heartily welcomed 
by the practitioner. 

DUNHAM, CARROLL, A.M., M.D. Homoeopathy the Science 
of Therapeutics. A collection of papers elucidating and illustrating 
the principles of homoeopathy. 529 pages. 8vo. Cloth, . . $3.00 

Half morocco, $4.00 

"More than one-half of this volume is devoted to a careful analysis of various drug- 
provings. It teaches ns Materia Medica after a new fashion, so that a fool can understand r 
not only the full measure of usefulness, but also the limitations which surround the drug. 
. . We ought to give an illustration of his method of analysis, but space forbids. We 
not only urge the thoughtful and studious to obtain the book, which they will esteem as 
second only to the Oryanon in its philosophy and learning.'' — The American Homceopathist. 

DUNHAM, CARROLL, A.M., M.D. Lectures on Materia 

Medica. 858 pages. 8vo. Cloth, 85.00 

Half morocco, 86.00 

" Vol. I. is adorned with a most perfect likeness of Dr. Dunham, upon which stranger 
and friend will gaze with pleasure. To one skilled in the science of physiognomy there 
will be seen the unmistakable impress of the great soul that looked so long and stea 
out of its fair windows. But our readers will be chiefly concerned with the contents of 
these two books. They are even better than their embellishments. They are chieiiy such 
lectures on Materia Medica as Dr. Dunham alone knew how to write. They are preceded 
quite naturally by introductory lectures, which he was accustomed to deliver to his classes 
on general therapeutics, on rules which should guide us in studying drugs, and on the 
therapeutic law. At the close of Vol. II. we have several papers of great interest, but the 
most important fact of all is that we have over fifty of our leading remedies presented in a 
method which belonged peculiarly to the author, as one of the most successful teacheis our 
school has yet produced. . . . Blessed will be the library they adorn, and the wise 
man or woman into whose mind their light shall shine." — Cincinnati Medical Advance. 

EDMONDS on Diseases Peculiar to Infants and Children. By 

W. A. Edmonds, M.D., Professor of Paedology in the St. Louis Homoeo- 
pathic College of Physicians and Surgeons, etc., etc., etc. 1881. Pp. 300. 

8vo. Cloth, $2.50 

This work meets with rapid sales, and was accorded a flattering reception 

by the homoeopathic press. 

" This is a good, sound book, by an evidently competent man. The preface is as manly 

as it is unusual, and engages one tp go on and read the entire work.. In the chapter on the 



HOMOEOPATHIC PUBLICATIONS. O 

examination of sick children we read that 'no physician will ever have full and comfort- 
able success as a psedologist who has a brusque, reticent, undemonstrative manner. It is 
indispensable that a physician having children in charge should convince them by his 
manner that he likes them, and sympathizes with them in their whims, foibles and peculi- 
arities. Their intuitions as to whom they ought to like and ought not to like are marked 
and wonderfully accurate at a very tender age.' The physician who writes thus is a born 

paedologist, and most assuredly a very successful practitioner 

''After the examination of children has been dwelt upon, our author proceeds to dis- 
cuss of the hygiene of children in a very able and sensible manner. He then discourses 
upon the various diseases of children in an easy and yet didactic manner, and any one can 
soon discover that he knows whereof he writes." — From the Homoeopathic World. 

EGGERT, DR. W. The Homoeopathic Therapeutics of Uterine 
and Vaginal Discharges. 543 pages. 8vo. Half morocco, $3.50 
The author here brought together in an admirable and comprehensive 
arrangement everything published to date on the subject in the whole homoeo- 
pathic literature, besides embodying his own abundant personal experience. 
The contents, divided into eight parts, are arranged as follows : — Part I. 
Treats of Menstruation and Dysmenorrhea. Part II. Menorrhagia. Part 
III. Amenorrhea. Part IV. Abortion and Miscarriage. Part V. Metror- 
rhagia. Part VI. Fluor albus. Part VII. Lochia, and Part VIII. General 
Concomitants. No w r ork as complete as this, on the subject, was ever before 
attempted, and we feel assured that it will meet with great favor by the profes- 
sion. 

GUERNSEY, DR. H. N. The Application of the Principles and 
Practice of Homoeopathy to Obstetrics and the Disorders Pe- 
culiar to Women and Young Children. By Henry N. Guernsey, 
M.D., Professor of Obstetrics and Diseases of Women and Children in the 
Homoeopathic Medical College of Pennsylvania, etc., etc. With numerous 
Illustrations. Third edition, revised, enlarged, and greatly improved. Pp. 

1004. 8vo. Half morocco, $8.00 

In 1869 this sterling work was first published, and was at once adopted as 
a text-book at all homoeopathic colleges. In 1873 a second edition, considerably 
enlarged, was issued; in 1878 a third edition -was rendered necessary. The 
wealth of indications for the remedies used in the treatment, tersely and suc- 
cinctly expressed, giving the gist of the author's immense experience at the bed- 
side, forms a prominent and well appreciated feature of the volume. 

" This standard work is a credit to the author and publishers. ***** The 
instructions in the manual and mechanical means employed by the accoucheur are fully up 
to the latest reliable ideas, while the stand that is taken that all derangements incidental to 
gestation, parturition and post partum are not purely mechanical, but will in the majority 
of cases, if not all, succumb to the action of the properly selected homoeopathic remedy, 
shows that Prof. Guernsey has not fallen into the rut of methodical ideas and treatment. 

The appendix contains additional suggestions in the treatment 

of suspended animation of newly-born children, hysteria, ovarian tumors, sterility, etc., 
suggestions as to diet during sickness of any kind, etc., etc. After the index is a glossary, a 
useful appendix in itself. Every practitioner should have a copy of this excellent work, 
even if he has two or three copies of old school text-books on obstetrics and diseases of 
women." — From the Cincinnati Medical Advance. 

GUERNSEY, DR. E. Homoeopathic Domestic Practice. With 

full Descriptions of the Dose to each single Case. Containing also Chap- 

, ters on Anatomy, Physiology, Hygiene, and abridged Materia Meclica. 

Tenth enlarged, revised, and improved edition. Pp. 653. Half leather, 

$2.50 

HAGEN, DR. R. A Guide to the Clinical Examination of Patients 
and the Diagnosis of Disease. By Richard Hagen, M.D., Privat 



D F. E. BOERICKE.S 

docent to the University of Leipzig. Translated from the second revised 
and enlarged edition, by G. E. Gramm, M.D. Pp. 223. 12mo. Cloth, 

$1.25 

" This is the most perfect guide in the examination of patients that we have ever seen. 
The author designs it only for the use of students of medicine before attending clinics, I wt 
we have looked it carefully through, and do not know of 2'2o pages "of printed matter any- 
where of more importance to a physician in his daily bedside examinations. It is simplv 
invaluable." — From the St. Louis Clinical Review. 

HAHNEMANN, DR. S. Organon of the Art of Healing. By Sam- 
uel Hahnemann, M.D. Aude Sapere. Fifth American edition. Trans- 
lated from the fifth German edition, by C. Wesselhoeft, M.D. Pp. 244. 

8vo. Cloth, §1.75 

"To insure a correct rendition of the text of the author, they (the publishers) selected 
as his translator Dr. Conrad Wesselhoeft, of Boston, an educated physician in every respect, 
and from his youth up perfectly familiar with the English and German languages, than 
whom no better selection could" have been made." "That he has made, as he himself 
declares, 'an entirely new and independent translation of the whole work,' a careful com- 
parison of the various paragraphs, notes, etc., with those contained in previous editions, 
gives abundant evidence ; and while, he has, so far as possible, adhered strictly to the letter 
of Hahnemann's text, he has at the same time given a pleasantly flowing rendition that 
avoids the harshness of a strictly literal translation." — Hahnemanman Jlonthly. 

HAHNEMANN, DR. S. The Lesser Writings of. Collected and 
Translated by E. E. Dudgeon, M.D. With a Preface and Notes by E. 
Marcy, M.D. With a Steel Engraving of Hahnemann from the statue 
of Steinhauser. Pp. 784. Half morocco, .... 83.00 

This valuable work contains a large number of Essays of great interest to 
laymen as well as medical men, upon Diet, the Prevention of Diseases, Venti- 
lation of Dwellings, etc. As many of these papers were written before the dis- 
covery of the homoeopathic theory of cure, the reader will be enabled to peruse 
in this volume the ideas of a gigantic intellect when directed to subjects of gen- 
eral and practical interest. 

HALE, DR. E. M. Lectures on Diseases of the Heart. In three 
parts. Part. I. Functional Disorders of the Heart. Part II. Inflamma- 
tory Affections of the Heart. Part III. Organic Diseases of the Heart. 
Second enlarged edition. Pp. 248. Cloth, .... 81.75 
" After giving a thorough overhauling to the lectures of Dr. Hale, •with the full inten- 
tion of a close criticism, I acknowledge myself conquered. True there are text books on 
the same subject of thrice the number of pages— more voluminous, but not so concise; and 
in this very conciseness lies the merit of the work. Students will find there everything 
they need at the bedside of their patients. It fills just a want long felt by the profession, 
and we can only congratulate Dr. Hale to have found in Messrs. Boericke & Tafel, pub- 
lishers who have done their work equally well." — Xorth American Journal of Homoeopathy. 

HALE, DR. E. M. Materia Medica and Special Therapeutics of 
the New Remedies. By Edwix M. Hale, M.D., Professor of Materia 
Medica and Therapeutics of the New Remedies in Hahnemann Medical 
College, Chicago, etc., etc. Fifth edition, revised and enlarged. In two 
volumes — Vol. I. Special Svmptomatologv. With new Botanical and 
Pharmacological Notes. Pp. 770. 1882. " Cloth, . . . So.00 

Half morocco, $6.00 

" Dr Hale's work on New Remedies, is one both well known and much appreciated on 
this side of the Atlantic. For many medicines of considerable value we are indebted to 
his researches. In the present edition, the symptoms produced by the drug investigated, 
and those which they have been observed to cure, are separated from the clinical observa- 
tions, by which the former have been confirmed. That this volume contains a very large 



HOMOEOPATHIC PUBLICATIONS. 7 

amount of invaluable information is incontestable, and that every effort has been made to 
secure both fulness of detail and accuracy of statement, is apparent throughout. For these 
reasons we can confidently commend Dr. Hale's fourth edition of his well known work on 
the New Remedies to our homoeopathic colleagues." — From the Monthly Homoeopathic Review. 

HALE, DR. E. M. Materia Medica and Special Therapeutics of 
the New Remedies. By Edwin M. Hale, M.D. Late Proiessor of • 
Materia Medica and Therapeutics of the New Eemedies in Hahnemann 
Medical College, Chicago ; Professor of Materia Medica in the Chicago 
Homoeopathic College, etc. Fifth edition, revised and enlarged ^thirty- 
seven new remedies), in two volumes. Vol. II. Special Therapeutics. 
With illustrative cases. Pp. 901. 8vo. Cloth, . . . $5.00 
Half morocco, $6.00 

" Hale's New Remedies is one of the few works which every physician, no matter how 
poor he may be, ought to own. Many other books are very nice to have, and xery desir- 
able, but this is indispensable. This volume before us is an elegant specimen of the 
printers' and binders' art, and equally enjoyable Avhen we consider its contents, which are 
not only thoroughly scientific, but also as interesting as a novel. Thirty-seven new drugs 
are added in this edition, besides numerous additions to the effects of drugs, previously dis- 
cussed. * * * * * We must say and reiterate if necessary, that Dr. Hale has hit the 
nail on the head in his plan for presenting the new remedies. It does well enough to tabu- 
late and catalogue,- for reference in looking up cases, barren lists of symptoms, but for real 
enjoyable study, for the means of clinching our information and making it stand by us, give 
us volumes planned and executed like that now under consideration." — From the New Eng- 
land Medical Gazette. 

HALE, DR. E. M. Medical and Surgical Treatment of the Dis- 
eases of Women, especially those causing Sterility. Second edition. 
Pp. 378. 8vo. Cloth, $2.50 

" This work is the outcome of a quarter of a century of practical gynaecological experi- 
ence, and on every page we are struck with its realness. It is one of those books that will be 
kept on a low shelf in the libraries of its possessors, so that it may be found readily at hand 
in case of need. It is a work that soon will be well-thumbed by the busy practitioner who 
owns it, because in many a difficult obstetric case he will pace his study, tug at the favorite 
button a little nervously, and suddenly pause and exclaim, 'Let us see what Hale says 
about it ! ' and in seeing what Hale does say about it he will feel strengthened and com- 
forted, as one does after a consultation with a hi'ilfreicher colleague in a difficult or dangerous 
case, in which the enormous responsibility had threatened to crush one. 

" In many obstinate uterine cases we shall reach this book down to read again and 
again what this clinical genius has to say on the subject. We have never seen Professor 
Hale in the flesh, but we have had scores of consultations with him in the pages of his 
New Remedies, and he has thus feelessly helped us cure many an obstinate case of disease. 

" When we get a good book we mentally shake hands with the author, and think grate- 
fully of him for giving us of his great riches. This is a good book, and thus we act and 
feel towards its gifted author, Professor Hale.' — From the Homoeopathic World, London. 

HART, DR. C. P. Diseases of the Nervous System. Being a 
Treatise on Spasmodic, Paralytic, Neuralgic and Mental Affections. For 
the use of Students and Practitioners of Medicine. By Chas. Porter 
Hart, M.D., Honorary Member of the College of Physicians and Sur- 
geons of Michigan, etc., etc., etc. Pp. 409. 8vo. Cloth, . • $3.00 

"This work supplies a need keenly felt in our school — a work which will be useful 
alike to the general practitioner and specialist ; containing, as it does, not only a condensed 
compilation of the views of the best authorities on the subject treated, but also the authors 
own clinical experience ; to which is appended the appropriate homoeopathic treatment of 
each disease. It is written in an easy, flowing style, at the same time there is no waste of 
words. * * * * * We consider the work a highly valuable one, bearing the evidence 
of hard work, considerable research and experience," — Medico-Chirurgical Quarterly. 

" We feel proud that in Hart's ' Diseases of the Nervous System ' we have a work up 



8 f. e. boericke's 

to date, a work which we need not feel ashamed to put in the hands of the neurologist or 
alienist for critical examination, a work lor which we predict a rapid sale." — North Ameri- 
can Journal of Homoeopauty. 

HELMUTH, DR. W. T. A System of Surgery. Illustrated with 
5(58 Engravings on Wood. By Wm. Tod Helmutii, M.D. Third 

edition. Pp. 1000. Sheep, S8.50 

This standard work, for many years used as a text-b >ok in all homoeopathic 
colleges, still maintain^ i.;s rank as the best work ever brought out by our school 
on the subject. Ever since it was issued the necessity, for the student or prac- 
titioner, to invest in allopathic works on the subject ceased to exist. It is up to 
date, and abounds in valuable hints, for it gives the results of the author's ripe 
and extensive experience with homoeopathic medication in connection with sur- 
gical operations. I ace of diction our author has never been approached. 

. . . . " We have in this work a condensed compendium of almost all that is 
known in practical surgery, written in a terse, forcible, though pleasing style, the author 
evidently ha .are gift of saying a great deal in a few words, and of, saying these few 
words in a graceful, easy manner. Almost every subject is illustrated wit'. m the 
doctor'* own practice; nor has he neglected to put be I advantage of homoe- 
opathic treatment in surgical diseases. The Avork is in every respect up to the require- 
ments of the times 

" Taken altogether. do book in our literature that we are more proud of. 

•' One word of commendation to the publisher- is nat irally drawn from us as we com- 
pare this handsome, clearly-printed, neatly-bound volume with the last edition. The dif- 
ference is so palpable that there is no necessity of making further comparisons." — Horaceo- 
pathic Times. 

HELMUTH, DR. W. T. Supra-Pubic Lithotomy. The High 
Operation for Stone — ■ Epicystotoruy — Hypogastric Lithotomy — "The 
High Apparatus." By Wm. Tod Helmuth, M.D., Professor of Surgery 
in the X. Y. Horn. Med. College ; Surgeon to the Hahnemann Hospital 
and to Wards Island Homoeopathic Hospital, X. Y. 98 quarto pp. 8 

lithographic plates. Cloth. Price, 84.00 

A superb quarto edition, with lithographic plates, printed in five colors, 

and illustrated by charts and numerous wood-cuts. 

HEINIGKE, DR. CARL. Pathogenetic Outlines of Homoeo- 
pathic Drugs. By Dr. CAel Heixigke, of Leipzig. Translated from 
the German by Emll Tietze, M.D., of Philadelphia. Pp. 576. 8vo. 

Cloth, 83.50 

' : The reader of this work will gain more practical knowledge of a given drug from its 
pages in the same space of time than from any other book on the same subject. 

•• The publishers' part of the work has been executed with the usual elegance, neatness 
and durability which L-haracvcrizes all their publications which we have seen. 

"To the English reading portion of our colleagues, this book will be a boon to be 
appreciated, in proportion that it is consulted, and will save thsm many weary researches 
when in doubt of the true homoeopathic remedy.'" — American Homoeopath. 

HEMPEL, DR. C. J., and DR. J. BEAKLEY. Homoeopathic 
Theory and Practice. With the Horace roathic Treatment of Surgical 
Diseases. Designed for Students and Practitioners of Medicine, and as a 
Guide for an intelligent public generally. Fourth edition. Pp. 1100. S3.00 

HERING, DR. CONSTANTINE. Condensed Materia Medica. 

Second edition, more Condensed, Revised, Enlarged and Improved. 806 
pages, large 8vo. Half morocco, ...... $7.00 

This, the most complete work issued from the pen of the late illustrious 
author, has a very large sale, having been adopted from its first appearance as 
Text-book in all Homoeopathic Colleges in the United States. 



HOMOEOPATHIC PUBLICATIONS. \) 

"This work, the author tells us, is made up from the manuscript prepared 'for the 
' Guiding Symptoms/ and is intended to give the student an idea of the main leatures of 
each drug in as narrow a compass as possible. It is, in fact, the ' Guiding Symptoms' boiled 
down. It has therefore a value of its own in enabling the student or practitioner to see 
quickly the chief symptoms of each medicine. Its name indicates its nature exactly, the 
condensation being more valuable from the hands of Dr. Hering than it might be from 
others of smaller experience. To those who wish to have such an aid to the Materia 
Medica beside them, we can recommend it.'' — Monthly Homoeopathic Meview for September, 
1880. 

" The favor with which this work has been received, and the rapidity with which it has 
been adopted as a text-book in all the homoeopathic medical colleges, attests most fully its 
value. Embracing the rich experience and the extensive learning of the author, its author- 
ity is unquestioned. The relationship of the drugs is peculiarly valuable, and can be found • 
nowhere else outside of Bcenninghausen. The schema is accordino- to Hahnemann, simi- 
larity in symptoms being clearly indicated. Hering's Materia Medica has now become the 
leading work of its kind in our school. Its broad pages lie invitingly before you. You 
read over the symptomatology of each drug with the consciousness that each and every line 
has been well considered before incorporation, and that it is a storehouse of wealth from 
which every worker can draw his supplies. The appearance of the work reflects credit 
upon the publishers, who have already gained their reputation as book publishers of the 
first rank." — Homoeopathic News. 

HERING, DR. CONSTANTINE. Domestic Physician. Seventh 
American Edition. 464 Pp. . . . . . . 82. 50 

The present editor, Claude E. Norton, M.D., a former assistant of Dr. 
Hering, undertook, at his desire, the task of superintending the publication of 
the work. Some additions to the text have been made, a few remedies intro- 
duced, and, at times, slight alterations in the arrangement effected, but the well- 
known views of the author have been respected in whatever has been done ; but 
for unavoidable reasons, the issue of the present edition has been delayed until 
this time. 

HOMCEOPATHIC POULTRY PHYSICIAN (Poultry Veteri- 
narian) ; or, Plain Directions for the Homoeopathic Treatment of the 
most Common Ailments of Fowls, Ducks, Geese, Turkeys, and Pigeons, 
based on the author's large experience, and compiled from the most reliable 
sources, by Dr. Fr. Schroter. Translated from the German. 84 pages. 

12mo. Cloth, S0.50 

We imported hundreds of copies of this work in the original German for 
our customers, and as it gave good satisfaction, we thought it advisable to give 
it an English dress, so as to make it available to the public generally. The 
little work sells very fast, and our readers will doubtless often have an oppor- 
tunity to draw thf attention of their patrons to it. 

HOMCEOPATHIC COOKERY. Second edition. With additions by a 
Lady of an American Homoeopathic Physician. Designed chiefly for the 
Use of such Persons as are under Homoeopathic Treatment. 176 pages. §0.50 

HULL'S JAHR. A New Manual of Homoeopathic Practice. 
Edited, with Annotations and Additions, by F. G. Snellixg, M.D. Sixth 
American edition. With an Appendix of the New Eemedies, by C. J. 

Heupel, M.D. 2 vols. 2076 pages, 89.00 

This iirst volume, containing the symptomatology, gives the complete 
pathogenesis of two hundred and eighty-seven remedies, besides a large number 
of new remedies added by Dr. Hempel, in the appendix. The second volume 
contains an admirably arranged Repertory. Each chapter is accompanied by 
copious clinical remarks and the concomitant symptoms of the chief remedies 
for the malady treated of, thus imparting a mass of information, rendering the 
work indispensable to every student and practitioner of medicine. 



10 F. E. BOERICKK'.S 

JAHR/DR. G. H. G. Therapeutic Guide; the most Important results 
of more than Forty Years Practice. With Personal Observations regard- 
ing the truly reliable and practically verified Curative Indications in actual 
cases of disease. Translated, with Notes and New Kemedics, by C. J. 

Hempel, M.D. 546 pages, $3.00 

"With this characteristically long title, the veteran and indefatigable Jahr gives us 
another volume of homoeopathies. Besides the explanation of its purport contained in the 
title itself, the author's preface still further sets lorth its distinctive aim. It is intended, he 
says, as a 'guide to beginners, where I only indicate the most important and decisive points 
for the selection of a remedy, and where 1 do not oner anything but what my own indi- 
vidual experience, during a practice of forty years, has enabled me to verily as absolutely 
decisive in choosing the proper remedy.' The reader will easily comprehend that, in carry- 
ing out this plan, I had rigidly to exclude all cases concerning which I had no experience 

of my own to offer We are bound to say that the book itself is agreeable, chatty, 

and full of practical observation. It may be read straight through with interest, and 
referred to in the treatment of particular cases with advantage." — British Journal oj Homoe- 
opathy. 

JAHR. DR. G. H. G. The Homoeopathic Treatment of Diseases 
of Females and Infants at the Breast. Translated from the French 
by C. J. Hempel, M.D. 422 pages. Half leather, . . . 82.00 
This work deserves the most careful attention on the part of homoeopathic 
practitioners. The diseases to which the female organism is subject are de- 
scribed, with the most minute correctness, and the treatment is likewise indicated 
with a care that would seem to defy criticism. Ko one can fail to study this 
work but with profit and pleasure. 

JONES, DR. SAMUEL A. The Grounds of a Homoeopaths Faith. 

Three Lectures, delivered at the request of Matriculates of the Department 
of Medicine and Surgery (Old School) of the University of Michigan. 
By Samuel A. Jones, M.D., Professor of Materia Medica, Therapeutics, 
and Experimental Pathogenesy in the Homoeopathic Medical College of 
the University of Michigan, etc., etc. 92 Pages. 12mo. Cloth (per 

dozen, $3), . . . ' ■ 80.30 

The first Lecture is on The Law oj Similars; its Claim to be a Science in 
that it Enables Perversion. The second Lecture, The Single Remedy a Necessity 
of Science. The third Lecture, The Minimum Dose an Inevitable Sequence. 
A fourth Lecture, on The Dynamization Theory, was to have finished the 
course, but was prevented by the approach of final examinations, the prepara- 
tion for which left no time for hearing evening lectures. The Lectures are 
issued in a convenient size for the coat-pocket ; and as an earnest testimony to 
the truth, we believe they will find their way into many a homoeopathic house- 
hold. 

JOHNSON, DR. I. D. Therapeutic Key; or Practical Guide for the 
Homoeopathic Treatment of Acute Diseases. Tenth edition. 347 pages. 

Bound in linen, . $1.75 

Bound in flexible leather cover, 2.25 

The same including twelve insets properly lined and headed for daily visits, 
$3.25, or the insets separately at $1 per set of twelve. Each inset will be found 
sufficient for a month's visits in ordinary practice and well supplies the usual 
visiting list, and this without a perceptible increase in bulk. 

This has been one of the best selling works on our shelves ; more copies 
being in circulation of this than of any two other professional works put to- 
gether. It is safe to say that there are but few homoeopathic practitioners in 
this country but have one or more copies of this little remembrancer in their 
possession. 



HOMOEOPATHIC PUBLICATIONS. 11 

" This is a wonderful little book, that seems to contain nearly everything pertaining to 
the practice of physic, and all neatly epitomized, so that the book may be carried very com- 
fortably in the pocket, to serve as a source for a refresher in a case of need. 

" It is a marvel to us how the author has contrived to put into 347 pages such a vast 
amount of information, and all of the very kind that is needed. No wonder it is in its 
tenth edition. 

"Bight in the middle of the book, under P, we find a most useful little chapter, or 
article, on ' Poisonings/ telling the reader what to do in such cases. — Homoeopathic World, 
London. 

JOHNSON, DR. I. D. A Guide to Homoeopathic Practice. De- 
signed for the Use of Families and Private Individuals. 494 pages. 

Cloth, $2.00 

This is the latest work on Domestic Practice issued, and the well and favor- 
ably known author has surpassed himself. In this book fifty-six remedies are 
introduced for internal application, and four for external use. The work con- 
sists of two parts. Part I is subdivided into seventeen chapters, each being 
devoted to a special part of the body, or to a peculiar class of disease. Part II 
contains a short and concise Materia Medica. The whole is carefully written 
with a view of avoiding technical terms as much as possible, thus insuring its 
comprehension by any person of ordinary intelligence. 

" Family Guides are often of great service, not only in enabling individuals to relieve 
the trifling maladies of such frequent occurrence in every family, but in the graver forms 
of disease, by prompt action to prepare the way for the riper intelligence of the physician. 

" The work under notice seems to have been carefully prepared by an intelligent physi- 
cian, and is one of the handsomest specimens of book-making we have seen from the house of 
Boericke & Tafel, its publishers." — Homoeopathic Times. 

LAURIE and McCLATCHEY. The Homoeopathic Domestic 
Medicine . By Joseph Laurie, M.D., Ninth American, from the Twenty- 
first English edition. Edited and revised, with numerous and important 
additions, and the introduction of the new remedies. By P. J. Mc- 
Clatchey, M.D. 1044 pages. 8vo. Half morocco, . ' . $5.00 
" We do not hesitate to endorse the claims made by the publishers, that this is the most 
complete, clear, and comprehensive treatise on the domestic homoeopathic treatment of dis- 
ease extant. This handsome volume of nearly eleven hundred pages is divided into six 
parts. Part I is introductory, and is almost faultless. It gives the most complete and 
exact directions for the maintenance of health, and of the method of investigating the con- 
dition of the sick, and of discriminating between different diseases. It is written in the 
most lucid style, and is above all things wonderfully free from technicalities. Part II. treats 
of symptoms, character, distinctions, and treatment of general diseases, together with a 
chapter on casualties. Part III. takes up diseases peculiar to women. Part IV. is devoted 
to the disorders of infancy and childhood. Part V. gives the characteristic symptoms of 
the medicines referred to in the body of the work, while part VI. introduces the reper- 
tory." — Hahnemannian Monthly. 

" Of the usefulness of this work in cases where no educated homoeopathic physician is 
within reach, there can be no question. There is no doubt that domestic homoeopathy has 
done much to make the science known ; it has also saved lives in emergencies. The prac- 
tice has never been so well presented to the public as in this excellent volume." — New. Eng. 
Med. Gazdte. 

LILIENTHAL, DR. S. Homoeopathic Therapeutics. By S. 
Lilienthal, M.D., Editor of North American Journal of Homoeopathy, 
Professor of Clinical Medicine and Psychology in the New York Homoe- 
opathic Medical College, and Professor of Theory and Practice in the New 
York College Hospital for Women, Etc. Second edition. «835 pages. 

8vo. Cloth, $5.00 

Half morocco, 6.00 

" Certainly no one in our ranks is so well qualified for this work as he who has done 

it, and in considering the work done, we must have a true conception of the proper sphere 



12 F. e. boericke's 

of such a work. For the fresh graduate, tills hook Avill he invaluable, and to all such we 
unhesitatingly and very earnestly commendit. To the older one, who says he has no use 
for this book, we have nothing to say. He is a good one to avoid when well, and to dread 
when ill. We also hope that he is severely an unicum." — Prof. Samuel A. Jones in American 
Observer. 

" .... It is an extraordinary useful book, and those who add it to their library 
will never feel regret, for we are not saying too much in pronouncing it the best work on 
therapeutics in homoeopathic (or any other) literature. With this under one elbow, and 
Ilering's or Allen's Materia Medica under the other, the careful homoeopathic practitioner 
can refute Niemayer's too confident assertion, 'I declare it idle to hope for a time when a 
medical prescription should he the simple resultant of known quantities.' Doctor, by all 
means buy Lilienthal's Homoeopathic Therapeutics, It contains a mine of wealth." — Prof. 
Chas. Gaichel in Ibid." 

LUTZE, DR. A. Manual of Homoeopathic Theory and Practice. 
Designed for the use of Physicians and Families. Translated 
from the German, with additions by C. J. Hempel, M.D. From the six- 
tieth thousand of the German edition. 750 pp. 8vo. Half leather, $2.50 

MALAN, H. Family Guide to the Administration of Homoeo- 
pathic Remedies. 112 pages. 32mo. Cloth, . . . $0.30 

MANUAL OF HOMCEOPATHIC VETERfNARY PRACTICE. 

Designed for all kinds of Domestic Animals and Fowls, prescribing their 
proper treatment when injured or diseased, and their particular care and 
general management in health. Second and enlarged edition. 68± pages. 

8vo. Half morocco, 85.00 

" In order to rightly estimate the value and comprehensiveness of this great work, the 
reader should compare it, as we have done, with the best of those already before the public. 
In size, fulness, and practical value it is head and shoulders above the very hest of them, 
while in many most important disorders it is far superior to them altogether, containing, as 
it does, recent forms of disease of which they make no mention." — Hahnemannian Monthly. 

MARSDEN, DR. J. H. Handbook of Practical Midwifery, with 
full Instructions for the Homceopathic Treatment of the Dis- 
eases of Pregnancy, and the Accidents and Diseases incident to 
Labor and the Puerperal State. J. H. Marsden, A.M., M.D., 315 
pages. Cloth, $2.25 

" It is seldom we have perused a text-hook with such entire satisfaction as this. The 
author has certainly succeeded in his design of furnishing the student and young prac- 
titioner, within as narrow limits as possible, all necessary instruction in practical midwifery. 
The work shows on every page extended research and thorough practical knowledge. The 
style is clear, the array of facts unique, and the deductions judicious and practical. We are 
particularly pleased with his discussion of the management of labor, and the management 
of moiher and child immediately after the birth, hut much is left open to the common 
sense and practical judgment of the attendant in peculiar and individual cases." — Homoeo- 
pathic Times. 

MORGAN, DR. W. The Text-book for Domestic Practice; being 
plain and concise directions for the Administration of Homoeopathic Medi- 
cines in Simple Ailments. 191 pages. 32mo. Cloth, . . SO. 50 
This is a concise and short treatise on the most common ailments, printed 

in convenient size for the pocket; a veritable traveler's companion. 

NORTON, DR. GEO. S. Ophthalmic Therapeutics. By Geo. S. 
Norton, M.D., Professor of Ophthalmology in the College of the New 
York Ophthalmic Hospital, Senior Surgeon to the New York Ophthalmic 
Hospital, etc. With an introduction by Prof. T. F. Allen, M.D. Sec- 
ond edition. Re-written and revised, with copious additions. Pp. 342. 
8vo. Cloth, . $2.50 



HOMOEOPATHIC PUBLICATIONS . 13 

The second edition of Allen & Norton's Ophthalmic Therapeutics has now 
been issued from the press. It has been re-written, revised and considerably en- 
larged by Professor Norton, and will, without doubt, be as favorably received 
as the first edition — out of print since several years. This work embodies the 
clinical experiences garnered at the N. Y. Ophthalmic Hospital, than which a 
better appointed and more carefully conducted establishment does not exist in 
this country. Diseases of the eye are steadily on the increase, and no physician 
can afford to do without the practical experience as laid down in the sterling 
work under notice. 

RAUE, DR. C. G. Special Pathology and Diagnosis, with Thera- 
peutic Hints. Second edition, re-written and enlarged. Pp. 1,072. 

Large 8vo. Half morocco or sheep, $7.00 

Tiiis second edition is brought down to date, and, rendered in Dr. Pane's 
own pregnant, terse style. These thousand pages will be found to be encyclopedic 
as to the comprehensiveness, and epitomatic as. to the condensed form of the in- 
formation imparted. 

" . . . . The first edition has 644 pages ; this new has 1,072, and if Raue has 
added 428 pages it was because tour hundred and twenty-eight pages of something solid had 

to find a place in this universe The present fdition is written up to date, tersely 

it is true, but so far as I have read, in consonance with the latest teachings i 

envy the practitioner who can read this second edition without learning something ; and I 
would say to the young graduate, in an expressive AVestern phrase, ' Tie to it.' It has 
become a platitude to compliment publishers, but, really, Boericke & Taiel, and the Globe 
Printing House, may well be proud of this book." — S. A. Jones in American Observer. 

REIL, DR. A. ACONITE, Monograph on, its Therapeutic and 
Physiological Effects, together with its Uses and Accurate 
Statements, derived from the various Sources of Medical Lit- 
erature. By A. Reil, M.D. Translated from the German by H. B. 

Millard, M.D. Prize essay. 168 pages, $0.60 

" This Monograph, probably the best which has ever been published upon the subject, 
has been translated and given to the public in English, by Dr. Millard, of New York. 
Apart from the intrinsic value of the work, which is well known to all medical German 
scholars, the translation of it has been completed in the most thorough and painstaking- 
way; and all the Latin and Greek quotations have been carefully rendered into English. 
The book itself is a work of great merit, thoroughly exhausting the whole range of the 
subject. To obtain a thorough view of the spirit of the action of the drug, we can recom- 
mend no better work." — North American Journal. 

RUSH, DR. JOHN. Veterinary Surgeon. The Hand-book to Veteri- 
nary Homoeopathy; or, the Homoeopathic Treatment of Horses, Cattle, 
Sheep, Dogs and Swine. From the London edition. With numerous ad- 
ditions from the Seventh German edition of Dr. F. E. Gunther's "Homoeo- 
pathic Veterinary." Translated by J. F. Sheek, M.D. 150 pages. 18mo. 
Cloth, " . $0.50 

SCHAEFER, J. C. New Manual of Homoeopathic Veterinary 

Medicine. An easy and comprehensive arrangement of Diseases, adapted 
to the use of every owner of Domestic Animals, and especially designed 
for the farmer living out of the reach of medical advice, and showing him 
the way of treating his sick Horses, Cattle, Sheep, Swine and Dogs, in the 
most simple, expeditious, safe and cheap manner. Translated from the 
German, with numerous additions from other veterinary manuals, by C. J. 
Hempel, M.D. 321 pages. 8vo. Cloth, .... $2.00 

SHARP'S TRACTS ON HOMCEOPATHY, each, . . 5 

Per hundred, $3.00 



14 F. e. boericke's 

No. 1. What is Homoeopathy ? No. 7. The Principles of Homoeopathy. 



No. 2. The Defence of Homce 
No. 3. The Truth of 
No. 4. The Small Doses of 
No. 5. The Difficulties of 
No. 6. Advantages of 



opathy. No. 8. Controversy on 

No. 9. Remedies of 

No. 10. Provings of 

No. 11. Single Medicines of 

No. 12. Common sense of 



SHARP'S TRACTS, complete set of 12 numbers, .... $0.50 
Bound, $0.75 

SMALL, DR. A. E. Manual of Homoeopathic Practice, for the use 

of Families and Private Individuals. Fifteenth enlarged edition. 831 
8vo. Half leather, . $2.50 



Manual of Homoeopathic Practice. Translated into German by C. 

J. Hempel, M.D. Eleventh edition.. 643 pages. 8vo. Cloth, $2.50 

STAPF, DR. E. Additions to the Materia Medica Pura. Trans- 
lated by C. J. Hempel, M.D. 292 pages. 8vo. Cloth, . $1.50 
This work is an appendix to Hahnemann's Materia Medica Pura. Every 

remedy is accompanied with <*xtensive and most interesting clinical remarks, 

arid a variety of cases illustrative of its therapeutical uses. 

TESSIER, DR. J. P. Clinical Remarks concerning the Homoeo- 
pathic Treatment of Pneumonia, preceded by a Retrospective View 
of the Allopathic Materia Medica, and an Explanation of the Homoeo- 
pathic Law of Cure. Translated by C. J. Hempel, M.D. 131 pages. 
8vo. Cloth, .... . . .... ... $0.75 

TESTE. A Homoeopathic Treatise on the Diseases of Children. 
By Alph. Teste, M.D. Translated from the French by Emma H. Cote. 

Fourth edition. 345 pages. 12mo. Cloth, . . . . $1.50 
This sterling work is by no means a new applicant for the favorable con- 
sideration of the profession, but is known to the older physicians since many 
years, and would be as well known to the younger had it not been out of print 
for nearly eight years. However, as orders for the work were persistently re- 
ceived from all quarters, we concluded to resurrect the book as it were, and 
purchasing the plates from the quondam publishers, we re-issued it in a much 
improved form, i. e., well printed on excellent paper. Dr. Teste's work is 
unique, in that in most cases it recommends for certain affections remedies that 
are not usually thought of in connection therewith; but, embodying the results 
of an immense practical experience, they rarely fail to accomplish the de- 
sired end. 

VERDI, DR. T. S. Maternity, a Popular Treatise for Young 
Wives and Mothers. By Tullio Suzzara Verdi, A.M., M.D., of 

Washington, D.C. 450 pages. 12mo. Cloth, . . . $2.00 

" No one needs instruction more than a young mother, and the directions given by Dr. 
Verdi in this work are such as I should take great pleasure in recommending to all the 
young mothers, and some of the old ones, in the range of my practice." — George E. Ship- 
man, M.D., Chicago, III. 

"Dr. Verdi's book is replete with useful suggestions for wives and mothers, and his 
medical instructions for home use accord with the maxims of my best experience in prac- 
tice." — John F. Gray, M.D., New York City. 

— — Mothers and Daughters : Practical Studies for the Conservation of 
the Health of Girls. By Tullio Suzzara Verdi, A.M , M.D. 287 
pages. 12mo. Cloth, ........ $1.50 



HOMOEOPATHIC PUBLICATIONS. 15 

"The people, and especially the women, need enlightening on many points connected 
with their physical life, and the time is fast approaching when it will no longer be thought 
singular or 'Yankeeish' that a woman should Le instructed in regard to her sexuality, its 

organs and their functions Dr. Verdi is doing a good work in writing such 

books, and we trust he will continue in the course he has adopted of educating the mother 
an 1 daughters. The book is handsomely presented. It is printed in good type on fine 
paper, and is neatly and substantially bound." — Hahnemannian Monthly. 

VON TAGEN. Biliary Calculi, Perineorrhaphy, Hospital Gan- 
grene, and its Kindred Diseases. 154 pages. 8vo. Cloth, $1.25 

" Von Tagen was an industrious worker, a close observer, an able writer. The essays 
before us bear the marks of this. They are written in an easy, flowing, graceful style, and 
are full of valuable suggestions. While the essay on perineorrhaphy is mainly of interest 
to the surgeon, the other essays concern the general practitioner. They are exhaustive and 
abound in good things. The author is especially emphatic in recommending the use of 
bromine in the treatment of hospital gangrene, and furnishes striking clinical evidence in 
support of his recommendation. 

" The book forms a neat volume of 150 pages, and is well worthy of careful study." — 
Medical Counselor. 

WILLIAMSON, DR. W. Diseases of Females and Children, 
and their Homoeopathic Treatment. Third enlarged edition. 256 

pages, . . . . . SJ.00 

This work contains a short treatise on the homoeopathic treatment of the 
diseases of females and children, the conduct to be observed during pregnancy, 
labor and confinement, and directions for the management of new-born infants. 

WILSON, DR. T. P. Special Indications for Twenty-five Reme- 
dies in Intermittent Fever. By T.' P. Wilson, M.D., Professor of 
Theory and Practice, Ophthalmic and Aural Surgerv, University of Michi- 
gan. 1880. 53 pages. 18mo. Cloth, . ; . . . $0.40 ' 
This little work gives the characteristic Indications in Intermittent Fever 

of twenty-live of the mostly used remedies. It is printed on heavy writing 

paper, and plenty of space is given to make additions. 

The name of the drug is printed on the back of the page containing the 

symptoms, in order that the student may the better exercise his memory. 

WINSLOW, DR. W. H. The Human Ear and Its Diseases. A 

Practical Treatise upon the Examination, Recognition and Treatment of 
Affections of the Ear and Associate Parts, Prepared for the Instruction of 
Students and the Guidance of Physicians. By W. H. Wixslow, M.D., 
Ph.D., Oculist and Aurist to the Pittsburg Homoeopathic Hospital, etc., 
etc., with one hundred and thirty-eight illustrations. Pp. 526. 8vo. 

Cloth. Price, . $4.50 

"It would ill-become a non-specialist to pass judgment upon the intrinsic merits of Dr. 
Winslow's book, but even a general reader of medicine can see in it an author who has a 
firm grasp and an intelligent apprehension of his subject. There is about it an air of self- 
reliant confidence, which, when not offensive, can come only from a consciousness of know- 
ing the matter in hand, and we have never read a medical work which would more quickly 
lead us to give its author our confidence in his ministrations. This is always the conse- 
quence of honest and earnest and inclusive scholarship, and this author is entitled to his 
meed." — Dr. S. A. Jones in American Observer. 

WORCESTER, DR. S. Repertory to the Modalities. In their Re- 
lations to Temperature, Air, Water, Winds, Weather and Sea- 
sons. Based mainly upon Hering's Condensed Materia Medica, with ad- 
ditions from Allen, Lippe and Hale. Compiled and arranged by Samuel 
Worcester, M.D., Salem, Mass., Lecturer on Insanity and its Jurispru- 



16 F. e. boericke's 

dence at Boston University School of Medicine, etc., etc. 1880. 160 

pages. 12mo. Cloth, $1.25 

"This Repertory to the Modalities is indeed a most useful undertaking, and will, without 
question.be a material aid to rapid and sound prescribing where there are prominent modal- 
ities. The first chapter treats of the sun and its effects, both beneficial and hurtful, and we 
see at a glance that strontium carb., anacardium, conium mac, and kali bich. are likely to be 
useful to patients who like basking in the sun. No doubt many of these modalities are 
more or less fanciful; still a great many of them are real and of vast clinical range. 

'"The book is nicely printed en good paper, and strongly bound. It contains IbO pages. 
We predict that it will meet with a steady, long-continued sale, and in the course of time be 
found on the tables of most of those careful and conscientious prescribes who admit 
the philosophical value of (for instance) lunar aggravations, effects of thunder-storms, etc. 
And who, being without the priggishness of mere brute science, does not ?" — Homoeopathic 
World. 

WORCESTER, DR. S. Insanity and Its Treatment. Lectures on 
the Treatment of Insanity and Kindred Nervous Diseases. By Samuel 
Worcester, M.D., Salem, Mass. Lecturer on Insanity, Nervous Dis- 
eases and Dermatologv, at Boston University School of Medicine, etc., 

etc. 262 pages, $3.50 

Dr. Worcester was for a number of years assistant physician of the Butler 
Hospital for the Insane, at Providence, R. L, and was appointed shortly after 
as Lecturer on Insanity and Nervous Diseases to the Boston University School 
of Medicine. The work, comprising nearly five hundred pages, will be wel- 
comed by every homoeopathic practitioner, for every physician is called upon 
sooner or later to undertake the treatment of cases of insanity among his pat- 
ron's families, inasmuch as very many are loth to deliver any afflicted member 
to a public institution without having first exhausted all means within their 
power to effect a cure, and the family physician naturally is the first to be put 
in charge of the case. It is, therefore, of paramount importance that every 
homoeopathic practitioner's library should contain such an indispensable work. 

"The basis of Dr. Worcester's work was a course of lectures delivered before the senior 
students of the Boston University School of Medicine. As now presented with some alter- 
ations and additions, it makes a very excellent text-book for students and practitioners. 
Dr. Worcester has drawn very largely upon standard authorities and his own experience, 
which has not been small. In the direction of homoeopathic treatment, he has received 
valuable assistance from Drs. Talcott and Butler, of the New York State Asylum. It is 
not, nor does it pretend to be, an exhaustive work; but as a well-digested summary of our 
present knowledge of insanity, we feel sure that it will give satisfaction. We cordially 
recommend it." — New England Medical Gazette. 





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